INTERNATIONAL CONFERENCE ON PREVENTING VIOLENCE

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Title: INTERNATIONAL CONFERENCE ON PREVENTING VIOLENCE
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medical ethics forum-20
FR. GEORGE V. LOBO SJ.

Informed Consent
Q.N.3 of the Patient's Bill of Bights (cf.
Medical Ethics Forum-19) states that “the
patient has the right to receive from his
physician information necessary to give
informed consent prior to the start of any
procedure and/or treatment." What is the
scope of this information?
The required information cannot amount to
"full disclosure". It would be unrealistic
to expect physicians to discuss with their
patients every risk of the proposed treatment,
no matter how small or remote. Some would
measure the required disclosure by good
medical practice". Others by what a
reasonable practitioner would have dared
under the circumstances. Such a standard
based merely on a so called professional
standard would go against the patient s
prerogative to decide on projected therapy,

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himself.
The patient's right of self-decision should
shape the boundaries of the duty to reveal.
That right can be effectively exercised only
if the patient possesses enough information

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to enable an intelligent choice.
The content of the disclosure rests in the
first instance with the physician. Ordinarily,
it is only he who is in position to identify
particular dangers. But on the basis of his
experience and the knowledge of his
patient's background and current condition,
he should be able to sense to what extent
revelation to the patient would be helpful
for the purpose of giving informed consent.
The materiality could be defined in the
following way. "A risk is material when a
reasonable person, in what the physician
knows or should know to be the patient's

condition, would be likely to attach
significance to the risk or cluster of risks in
deciding whether or not to forgo the
proposed therapy."
The areas demanding a communication of
information are the inherent and likely
hazards of the proposed treatment, the
alternatives to that treatment, if any, and
the results likely if the patient remains
untreated. The advantages of the treatment
as well as the costs would also be material
to the decision.
There are two exceptions to the general
rule ol disclosure. The first comes into play
when the patient if unconscious or otherwise
incapable of consenting, and harm from a
failure to treat is imminent and outweighs
any harm threatened by the porposed
treatment. If possible, a relative's consent
should be obtained.
The second exception obtains when the
disclosure about the risk poses such a threat
of detriment to the patient as to become
contra-indicated from a medical point of
view. Occasionally, patients become so ill or
emotionally distraught on disclosure that
they would be incapable of rational decision,
or complicate the treatment. The disclosure
may even pose psychological damage to the
patient.
Such exceptions, however, do not justify a
paternalistic attitude in normal cases on the
part of the physician. The right of the
patient to make an informed decision should
be safeguarded.
A Verbal explanation may be sufficient, Bi|t
to avoid legal complications, a written
25

JANUARY-FEBRUARY '81
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medical ethics forum-21

KJ ■

FR. GEORGE V. LOBO S.J.

4

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Q. Has a physician or hospital the right
to impose a life-saving procedure against
the express will of the patient ?
The ethical principle presumed here is that
one has the obligation to use ordinary
means of saving life, but not extraordinary
means. One is not bound to submit to a
treatment with pain, expense or other
inconvenience that is disportionate to the
the expected advantage. Normally, the
patient has the right to make the decision
after being duly informed of the
implications (regarding the duty of the
physician to inform see Medical Ethics
Forum—20).

I
1

Here are some situations in which the
patient's right to refuse treatment seems to
call for respect : 1) blood transfusions to
replace loss of blood by intestinal
bleeding in a non-emergency
situation; 2) surgery when otherwise death
is inevitable over a period of time, but the
danger is not immediate; 3) regular
transfusions and removal of the spleen for
terminal hemolytic anaemia. In some of these
cases, there may be a stricter moral
obligation to undergo the treatment. But if
due regard is paid to the patient's right to
decide, it would not seem right to impose
the treatment. The courts in the United

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States have upheld the right of the patient
to refuse treatment in such situations.
However, in the case of an emergency, the
interest of society would override the desire,
presumed unreasonable, of the patients not
to accept the treatment. Just as society has
the right to prevent suicide, it has also the
right to intervene when a patient refuses
treatment in such a way as to clearly amount
to the immediate causation of death. It is
immaterial whether the refusal is motivated
by the will to die or for religious reasons as
in the case of refusal of blood transfusions
Jehovah's Witnesses.
An example when a treatment could be
imposed would be that of an otherwise
healthy person whose leg has been crushed
by a car accident and would need an
immediate amputation if his life is to be
saved. He might refuse to consent saying :
°l came into life with two legs and Tam
going out with two legs." Just as it is
assumed that an unconscious patient, if
capable would consent to emergency
treatment, it seems justified to assume that
this refusal of lifesaving aid, however
incapacitating, is due to weakness, confusion,
and pain rather than deliberation. The matter
would be clearer if the lifesaving treatment
could be administered with relatively little
pain or consequence.

St. John’s Rural Bond Scheme
St. John's Medical College, Bangalore, has a Rural Bond Scheme. After graduation, the
young doctors are encouraged and supported to work in rural areas for two years. On conpletion of their term, they will be also awarded a bonus of Rs. 4,800/- each. Dr. Ravi Narain

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is the coordinator of the scheme.
The doctors now work under the scheme are : Drs. Donald Fernandes, Anthony A Ferna
ndes, G. D. Ravindran Leslie D'Souza, Manuel Joseph, Davies M.S., Joseph Vampilly, Maries
Jose and K.R. Antony.

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FR. GEORGE V. LOBO S. J.
CASE : 50 people were killed when a
a bus driver had a heart attack and plung
ed his bus into a river. The driver's physi
cian had known about the bad heart, had
cautioned him not to drive, but did not
think it right to report it to the company
since the patient might lose his job. Was
his attitude right ?

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THE physician has a prima facie obliga
tion to preserve the principle of medical
confidentiality. The obligation is based on two
important considerations. The first is based on
possible long-term consequences, viz., the
obstacle there would be for full disclosure of
symptoms and their causes if there was the
fear of disclosure of the information. The
second is the right of the patient to a sphere
of privacy. Each individual has the right of
determining, ordinarily, to what extent his
condition, thoughts and feelings shall be
communicated to others. From this stand
point, the right becomes more or less strin
gent according to the nature of the secret,
that is, how far it belongs to the centre or
'core self' of the personality.

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These two reasons provide a strong case
for medical confidentiality. Still, the princ
iple of confidentiality is not an absolute. It
may be overridden by other considerations.
The right to confidentiality may come into
conflict with other rights of the patient him
self or those of others. For instance, a pat-

listers'
or in a ,
bly be
one of
So far
Drs has
ashtra,
Andhra

ient, in a fit of depression, may threaten to
kill himself or another. If the threat is serious,
the physician may feel free to reveal the
situation if there is no other way of counter
ing the threat.
In the present case, the physician did
well in cautioning the patient not to drive.
But if the patient was willing to consider the
warning seriously, a case may be made out
for the physician's right and even duty to
warn the company. This is ail the more so
since this bit of information does not belong
to the inner core of the self, but more to
outer circumstances.
The prospect of the patient losing his job
could be considered, but this does not seem
to be a significant factor since a person with
a weak heart is not eligible to be a bus driver.
The risk of such a person involving others
in an accident is high and hence the danger
of his losing such a job does not give him
the right to confidentiality regarding the con
dition of his health.
So the physician could consider revealing
the information to the right quarters. The
need for breaking professional secrecy in such
cases would not arise if the bus company
itself periodically gets its employees to have
a medical check up. Then the question of
confidentiality regarding vital information
related to the job does not arise.

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medical ethics forum

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------

Pushpa Hospital,
Roshina, Hassud, U. P.
Catholic Mission Dispensary
Kotturu, Srikakulam, A. P;
St. Joseph's Hospital
Ountur, A. P.
Social Action Dispensary
Poonamallee, Madras

165-00

64-00
200-00

100-00

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150-00
St Augustian's Hospital
Springvalley, Kumily
A Donor from West Germany
(through Fr. John Vattamattom
3,500-00
SVD)
50-00
Sacred Heart Leprosy Centre
Sakkottai, Thanjavur, Tamil Nadu

Total

MAY-JUN E 81

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Medical Ethics Forum - 39

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Fr. George Lobo, sj
Human

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and

Animal

Life

Q: Human personality implies consciousness and capacity for interelation ships.
These are lacking in the fetus as well as in
a person in irreversible coma. Hence, what
is wrong in their life when there is a good
reason to do so?
A:
Species is determined
by the
characteristics of normal individuals belonging
to it. Thus, consciousness and capacity for
relationship determine the normal human
person. But these characteristics need not
be realized at every stage. The fetus is
going to intrinsically develop into a conscious
and relational being and hence is already a
person. It is an actual, although undeveloped
person, and not merely a potential person.
Its capacities may be in potential, but the
personality itself is actual. Everyone knows
that a human embryo is quite different from
a cat's embryo although both may look tiny
and helpless.
The same is true at the end of life. We
may end the suffering of an injured cat by
'putting it to sleep'. This may at times be
the most humane way of handling the situa
tion. However, it is never humane or merciful
to do so in the case of a man or woman.
Personhood remains even in extreme decrepi
tude or suffering. The only human thing to
do is to manifest our compassion by our care

and concern. We show genuine love and
respect for such a person, not by killing him
or her, but by trying to provide as best as
possible what he or she needs to continue
living with the least pain and the greatest
alertness the condition permits.

ma
tioi
Ce
pu'
set
ma
A J
Tra
irre
be
um
tre-

Both the patient as well as the family need
support. Even when drugs fail to provide relief, a
hospice like atmosphere has proven effective in
the pain management if say, a cancer patient.
The emotional and financial stress resulting
from a prolonged illness of a family member
can be overwhelming.
Society has the
obligation to provide the needed support
While we may never 'despatch' an in
curably sick and suffering person, as we might
an animal, we are not obliged to use ex
traordinary means or unduly prolong the
process of dying. We are not to play God
either by usurping His Sovereign right over
human life or by using disproportionate
means that do not result in any tangible
benefit but only aggravate the distress of the
patient and the family.

me
Kri.
Ku
Kri;
tha
like
de|
afft
gul
ma
nec
suf
for

It should be noted that in the discussion
on abortion, infanticide or euthanasia, often
the question of the unique dignity and sanctity
of human life is implied. A same medical
ethic presupposes that man is made to the
image of God and hence human life has a
unique value compared to animal life.

Mr
of
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Dr.

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Medical Service

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MEDICAL ETHICS FORUM-38

con-

Fr. George Lobo S.J.

inding
com□r our
share
ght of
3 that

Passive Euthanasia — Prof. Varde's Bill
Sri M.C. Daga's Mercy Killing Bill of 1980
in the Indian Parliament received the sum
mary rejection which it deserved.
Mercy
killing' remains killing of a human being
whatever the situation or motive. Life is the
most basic of human valuesand no one has
the right to take it. God alone is the Master
of life and man is only its steward. The role of
the medical profession is to preserve and
promote human life and not to destroy it.

I

In 1984, Prof. S. Varde has moved a bill
in the Maharashtra State legislature which
does not permit active killing, but sanctions
withdrawl of all artificial treatment in terminal
illness which will "in all probability result in
the expiration of life", if the patient when
competent so willed. The idea is to assure civil
and criminal immunity of a physician or surgeon
adopting the measure.

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to take the decision to refuse forms of treat
ment that would only secure a precarious and
burdensome prolongation of life so long as the
normal care due to the sick person in similar
cases is not interrupted." This position strikes
a balance between the respect due to human
life even in terminal illness and the limitation
of human intervention to prolong life. It is the
restatement of the traditional position that,
while one may never directly terminate human
life, one is only obliged to take ordinary
means of preserving it.
Varde's bill would extend withdrawl of
treatment even when there is only probability.
It would sanction withdrawl of 'all artificial
treatment'. This would in fact amount to homi
cide, albeit by an act of omission. Killing is
killing whether it is done by an act of com
mission or one of omission. It would thus
inevitably pave the way to active euthanasia.

It is good to note that the bill clearly exclu
des active killing or any positive act directed
to destroy or terminate life. It is also laudable
that the mover of the bill himself asked that it
be referred to a select committee of the legi
slature and that it be opened to public debate.
The ensuing debate has been quite lively and
on the whole quite enlightening. It has also
brought to light the problem of many sufferers
in terminal illness so that the need for proper
care, among other ways, in hospitals, has
become clearer. Still, the bill is to be faulted on
several grounds.

Varde is not clear on what he means by
withdrawl of 'all artificial treatment'. Would it
include intravenous or naso-gastral feeding ?
Also any special diet? Ultimately, would his
bill not lead to the sanctioning of total
neglect or of starving out of the patient?

The 1981 Vatican Deciration on Euthanasia,
to which Prof. Varde has referred to, states:
''When
in spite of
the means used, it is permitted in conscience

The 'power of attorney' to be granted to
the doctor would imply the awesome responsibility of deciding when the patientshould die
when the role of the doctor is to preserve life.

Service
February-March 1986

The patient is supposed to manifest his
choice regarding the withdrawal of treatment
when he is of 'sound mind'. What is meant by
this? Would a person in really 'sound mind'
want to have his life terminated, even it be by
negative means?

87

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As it happened in the case of the Medical
Termination of Pregnancy Act, mere permissi
bility of passive euthansia would inevitably
lead to compulsion. It would result, not in
immunity from legal action, but coercion to
abandon treatment at the behest of the
patient.
A modified bill granting immunity to
doctors might have been necessary if the
Indian State interfered with the discretion of

the doctor together with the patient/family to
discontinue extraordinary treatment. But there
is no evidence that there is now such an inter
ference. Hence, even the positive features of
the bill are superflous.
Since the bill is objectionable for all these
reasons, it would be best for the mover to
withdraw it. If Varde had in mind the pro
voking of a debate of the issue, he seems to
have already achieved his purpose.

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Powerec
This mode
1.18 litre ei
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The synchr
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change an

Planning of New Hospital ?
Expanding Existing Nursing Home ?
Modernising facilities ?
Consider "JANAK" for the Patient Care Beds such as Intensive Care Bed,
Recovery Bed, Hi-Low Bed, Modified Fowler's Bed, Bed with backrest.
Emergency & Recovery Trolley, Obstetric Labour Table 2 Section, Medical
Tables, Trollies Wheel Chair and other Ward furniture
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METALBEDS INDIA (in association with Janak Mfg. Works)
Janak House, Opp. Indian oil Corpn Depot.
Sheikh Misry Road, Wadala (East)
Bombay-400037

Takes on
The well-si
good road
ground cle
for out-of-c

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Tel: 8820171/8820769

Fade-resist
front whee
for reducec

Cable : JANAKBED (MT)
Telex : 011-71584 JKMG IN

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88

Medical Service

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KA-PNE-12-85

MEDICAL ETHICS FORUM—38

bil
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— Fr. George Lobo sj

Passive Euthanasia — Prof. Varde's Bill
Shri M.C. Daga's Mercy Killing Bill of
1980 in the Indian Parliament received the
summary rejection which it deserved. 'Mercy
killing' remains killing of a human being
whatever the situation or motive. Life is the
most basic of human values and no one has
the right to take it. God alone is the Master
of life and man is only its steward. The role
of the medical profession is to preserve and
promote human life and not to destroy it.
In 1984, Prof. S. Varde has moved a bill
in the Maharashtra State legislature which
does not permit active killing, but sanctions
withdrawl of all artificial treatment in ter
minal illness which will "in all probability
result in the expiration of life", if the patient
when competent so willed. The idea is to
assure civil and criminal immunity of a phy
sician or surgeon adopted the measure.
It is good to note that the bill clearly ex
cludes active killing or any positive act direct
ed to destroy or terminate life. It is also laud
able that the mover of the bill himself asked
that it be referred to a select committee of the
legislature and that it be opened to public
debate. The enusing debate has been quite
lively and on the whole quite enlightening.
It has also brought to light the problem of
many sufferers in terminal illness so that the
need for proper care, among other ways, in
hospices, has become clearer. Still, the bill
is to be faulted on several grounds.
The 1981 Vatican Declaration on Eutha
nasia, to which Prof. Varde has referred to,
states: ''When inevitable death is imminent
in spite of the means used, it is permitted in
30

i

ca
mi
ev
no
cic
the

conscience to take the decision to refuse
forms of treatment that would only secure a
precarious and burdensome prolongation of
life so long as the normal care due to the sick
person in similar cases is not interrupted."
This position strikes a balance between the
respect due to human life even in terminal
illness and the limitation of human interven
tion to prolong life. It is the restatement of the
traditional
position
that, while one may
never directly terminate human life, one is
only obliged to take ordinary means of pre
serving it.

do
W

Varde's bill would extend withdrawal of
treatment even when there is only probability.
It would sanction within drawal of "all arti
ficial treatment'. This would in fact amount
to homicide, albeit by an act of omission.
Killing is killing whether it is done by an act
of commission or one of omission. It would
thus inevitably pave the way to active eutha
nasia.

F
E

Varde is not clear on what he means by
withdrawal of 'all artificial treatment'. Would
it include intravenous or naso-gastral feed
ing? Also any special diet. Ultimately, would
his bill not lead to the sanctioning of total
neglect or of starving out of the patient?

b
*

C
s
E
t

The patient is supposed to manifest his
choice regarding the withdrawl of treatment
when he is of 'sound mind'. What is meant
by this? Would a person in really'sound mind'
want to have his life terminated, even it be
by negative means?
The 'power of attorney' to be granted to
the doctor would imply the awesome responsiMedical Service

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bility of deciding when the patient should die
when the role of the doctor is to preserve life.
As it happened in the case of the Medi
cal Termination of Pregnancy Act, mere per
missibility of passive euthansia would in
evitably lead to compulsion. It would result,
not in immunity from legal action, but coer
cion to abandon traatment at the behest of
the patient.

3

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<
e
il

A modified bill granting
immunity to
doctors might have been necessary if the

e
y
s

Indian State interfered with the discretion
of the doctor together with the patient/family
to discontinue extraordinary treatment. But
there is no evidence that there is now such an
interference. Hence even the positive fea
tures of the bill are superflous.
Since the bill is objectionable for all these
reasons, it would be best for the mover to
withdraw it. If Varde had in mind the pro
voking of a debate of the issue, he seems to
have already achieved his purpose.

With this Fr. George Lobo Restarts his series Medical Ethics forum.

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Planning of New Hospital ?

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Expanding Existing Nursing Home ?
^y
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nt
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to
si
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Modernising facilities ?

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Consider "JANAK" for fine Patient Care Beds such as Inten
sive Care Bed, Recovery Bed, Hi-Low Bed, Modified Fowler s
Bed, Bed with backrest. Emergency & Recovery Trolley, Obste
tric Labour Table 2 Section, Medical Tables, Trollies Wheel
Chair and other Ward furniture
METALBEDS INDIA (in association with Janak Mfg. Works)
Janak House, Opp. Indian oil Corpn Depot,
Sheikh Misry Road, Wadala (East)
Bombay-400037

Tel : 8820171/8820769
Cable : JANAKBED (MT)
Telex : 011-71584 JKMG IN
January 1986

31

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;f MEDICAL ETHICS FORUft

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Value Judgements in Health Care

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,s my/eeHngu^l;
mAn in
• • 9
.man
in me._whrk
-4®
ick observe, .ttekel-:
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, u^t W 'nection-seekir^
•
1' Case: Ram Prasad was brought into
ima taughtmea I the hospital emergency room by the
physical > traffic police. It was a case of
b hr
anguioii.andthe I compound fracture of the femur. Dr.
and above afl j Rao, the orthopedist set the bones
ie kept and the 1 and wrote out the order for
tely tried to hold I proponyphene as pain medication,
I angelic... sweet 1 This is a common drug for moderate
as the picture of k - pain supposedly lacking addictive
]ilein the face of i
properties. When the patient began
Jt I was told she j . to recover from the anesthetic, he
despair, not in i
began to moan louder and louder. The
but as a fulfilled
prescribed drug did not provide relief.
t her fight, ran j
As he pleaded for something
it her faith all
stronger, the nurse phoned to Dr.
e family and the I
Sharma, the resident on call. In order
I them so.
to calm the screaming, agitated
I
patient, he prescribed a heavy dose
of the potent methodone.

of
se
er
rs
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of
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The following morning, Dr. Rao was
furious at the resident ’s use of
j
methodone and told him: "Do you
want the patient to turn into an
addict just to relieve some pain?" Tne
resident argued that the physician’s
11 job is to relieve pain with all the tools
I of modern science. Dr. Rao affirmed
that the physician's role is to help
i|' nature take its course and not
tamper with the system in such a
Way that may cause addiction.
This case of a ordinary broken leg
brings out the different approaches
to handling the pain. Who is right?
Perhaps both; perhaps neither fully.
What may not be evident is that
Critical value choices are being made

Fr George Lobo sj

in even the most routine medical
problems. It is not only scientific
___is_______
medical knowledge that
involved,_
but also values with which the
alternatives are assessed. Frequently, the values present themselves
so clearly that they are just
assumed. But in a critical situation
like when someone would rather die
than bear with a misery, they
surface. .
Whenever in a medical situation,
more than one plausible alternative
exists, the choice must be based on a
clear system of values. In the
present case, there are two
alternatives: 1) Is man, particularly
medical man, to be the huler over
nature so that he can use any and
every technological tool to handle the
problem of suffering and misery in
the world, as Dr. Rao maintains?
2) Or, is man the servant of nature,
helping nature to take its course, as
Dr. Sharma asserts?
Modern medicine can produce
dramatic results. At the same time,
it can cause serious side-effects,
even what is called intra-genic or
physician-made illness. It can also
produce a depersonalizing effect,
Hence there can be different and, at
times, conflicting perceptions regarding the use of modern medicine,
Besides, one doctor may be more
oriented to the long-term consequences or the possible addiction:

another may concentrate on th
more immediate problem of relievir
pain.
Finally, there is the problem of wh
should decide. In this case, both th
doctors feel they have the authorr
to make decisions based on the
system of values. The nurs
assumes that her role in sue
matter is to follow the 'doctor
orders’. The patient’s wishes may
not be neglected. But he may not
have the knowledge to make a
considered choice. He may be the
victim of the conflict between the
physicans.
The only solution is open
discussion and frequent consultation
between the physicians. At times
the report of the nurse would b
significant. As far as possible, the
patient should be enlightened so that
he or she make an informed choice,
or give informed consent to the
physician’s proposal. In every
situation, the best interests of the
patient should be the prime
consideration. The question of
prestige and rivalry should not enter
the picture.
In order that the consultation
between the physicians might be
fruitful, they should be aware of each
other's value orientation and respect
it. They should see whether there
could be some convergence in these
orientations, at least as far as the
concrete case is concerned,

■

;i-

HEALTH ACTION OCTOBER 1983 • 35

MEDICAL ETHICS FORUM

Human Foundations of
community health
Fr George Lobo S J

■ or the ancients, health was
symptomatic of a correct relationship between man and his environment: His supernatural environment,
the world around him and his fellow
human beings. Hence health was

programme. The value of human life,
meaning of pain and the significance
of death are vital factors that should
not be lost sight of in dealing with the
patient. Different cultures have
different myths •’and practices

related to the community and its . regarding life events like illness and
culture. As an African saying goes: “A child birth. They may be more or less
manjs a man by means of other valid, but the patient is inevitably
mennaffected by them and cannot be
Modern medicine has largely adequately treated without the
abandoned this, approach and has healers recognizing them.
become largely technological and. 2 The cure of sick individuals cannot
individualistic. While scientificadvan- be effected without paying sufficient
ces provide a more accurate attention to the social condition
diagnosis regarding the particular which often gives rise to illness. How
ailment, and a more-.effective can, for instance, chronic bronchitis
treatment for it, there is need for be handled without tackling the
restoring the traditional holistic and problem of industrial smoke which
,
,
communitarian dimensions of the [people are breathing in. Even genetic
processof healing. In fact, the World disorders can
be aggravated
by
ozn .,2
aggravated
hv
yy dvdLeo oy
Health Organization defines health epigenetic or environmental factors,
“as a state of complete physical, Psychiatric conditions cannot be
mentalav\b soc/a/well-being.,’(1946) effectively treated without sufficient
“Healing” is “wholing" or restoring attention to the family, social or work
of the whole person
in Ihis situations which cause the stress
relationships as well as of every
3 Hospital medicine, inspite of its
person in the community. Human
undoubted value, cannot alone meet
health is that of a living organism of
the needs of the people in developing
the human species that is distingui
countries. This need for a more rural
shed from others by its personhood,
and community based system of
hat is, its capacity for relationships
health care. The local group must be
actualized only in truly human
seen as a healing community. While
community.the help of skilled professionals is
These basic realities regarding needed, the community itself should
human nature call for a community be helped to meet its basic health
concept of health. This implies:needs. The bulk of health workers
1 The beliefs of the community to should be recruited from amonq the
which the person belongs
be taken ---residents.
They shouldI for
the
.
-~
• VI I uJ most I
M I 'V* v IMmost
into account in tc_
’
the therapeutic part be trained
in the local context

Beware of pain
killers: expert

A
pharmacologist
has
cautioned against use of combination
pain killers containing “glucocorti
coids” that can cause adverse
effects from peptic ulcer to bony
lesion.
48 • HEALTH ACTION JULY 1989

although sending them
time to bigger centres can bS
There is room for qualified ins!
tors coming from outside rj||
thev are well acauaint'pri
V
cquamted
conditions and are able to -die,
positive elements in tradS
practices.
4 The principle of subsidian^
as in other fields, should be obs$
Higher levels should intervejR
when lower levels cannot orJvi
assume responsibility. The 1$
tion of higher levels should, a
possible, be in the line of tappi
resources and stimulating
community to a healthy way
prevention of disease, main
ecological balance and the prq
of positive health.
e
5 tu
-|-^e concept ofl communig

1

at the national level should)
proper priorities in the utilia
scarce financial and prof?
resources. Primary and pre
health care must receive top
The therapeutic wisdom of4
should not be allowed to befc
while modern advances ard
tec^ when they serve the ne^
r
people.
6 The hospital is a mirrpW
beliefs about man and sociel?
for
is
need
modef^M
functioning on the pattern ®
c.......
..
communities
so that the
patients are restored to con
functioning and the heaft
—itself grows in community*f
and finds vocational

Fron>J
Prof AK Grover of the All-lndia obesity, infections,euphojj
!
L Medical
Sciences ulcer, bony lesion and di^
market has been warned
while
speakinQ
Zi Saiu
oo ed with pain killers containing ' symposium on Pa*n s-.
glucocorticoids because it gives recently by the south DW
instant relief.
the |ncjjan Medical Assr^
But the use of corticoids for long
duration or in heavy doses for short
duration can lead to hypertension,

TQsandSOs
^ity Health
with the inc
Efevel field ex
iLgls are unfort
the prese
health initiate
known or as
y^ommunity
jyaphy has id
rials. A shorter

ifere highligh tir
sand Source
dian Council
Delhi

IgiveApf
-ition of
rammes, 1
opriate T(
ii Care. 19

;ry of I
New Delb
fi Services
tstava Repc
ual for Corr
ual for Hea
& II. 1979
ual for Healt
1979
for Heal

JeJ 1980

Health (

J980

Jfcook for t

>uLand
c!
J^P^eot Bic
83980

?Pr«end Ci
**ch of Oja
^system c

l^'Medic
^elhiea!t
aVi'Iage I
“leProce
Child H
no
Healt

'O.- '

Jl

'
- ■

-b-

—'

MEDICAL ETHICS FORUM

Ir

Fron-

^Ethics Forum
■

rnsofryjll
wers
dewing to*5.
3thing in
Jy TV sets/a'k
t has Warnfijg
)rthernpo^3
-ral hoursW
and other j
l°Wn

Ytni?

Ejections on
Bbetes
PStrflP Lobo, S J

BB-- -

l&fetPS is a fast spreading
.B^ith several complications
j to the dioxin
Bich at times can be fatal. Now
nd suspectra-’ BElknown that it is to a certain
C|ty enviray^B
B»Jiereditary, but is largely due
ialist Fritz Va^l
Od food habits and tensions,
lay. He added
guttering the high risk the disease
panic.
&y;spveral precautions are in
the gas
television hadhjW
itinually for th«
EF-tfie incidence of diabetes is
that fatird
Secularly high in some families,
tersection/' w
ft would be need for caution in
sfering into mutual wedlock since
ople to open Mb
atching telea**children might be adversely
especially if#
bought set for!
— Deccan

g

-4

-^3

;he person d?
:tivity like
jh the person®
ained lOKgte*
the percent#?
vill make it^
□ reduce
is less m1^

nkavil
iad

.

T.

■

onset of the disease could
jibe prevented by a balanced
Egular exercise and avoiding
ig and alcohol consumption,
fe also the need for avoiding
^p sary tensions.
’j

■yOnemust have prompt recourse
^atment when a higher than
■M-.-'blood sugar count is
^ad. There is need for observing
gjct dietary regime including the
of tobacco and alcohol,
g^tion without diet control may
of much use. However, there
jJ? be no undue anxiety about the
FJV. or quality of food. The
'tself can aggravate the
iteh* ^ne can eas*ly become a
> ondriac in this matter. There
Post h need f°r refrainin9’ as far
ssible from stressful occupa-

4 •Medical personnel should
provide accurate and rational
information regarding the diet. The
Consumer Protection : No lukewarm
advice must take into account the 39 attitude
availability of the particular food
by Srinivas Narayanswami
items in the place and during the
Consumer Confrontation
March-April 1989 P 12-14
season. At times, the advice differs
from doctor or hospital to hospital.
Patients have been known to have VI Environmental Issues
collapsed from hypoglyceamia due to 40 Vanishing Forests
environmental
Hazards and worsening Poverty
undue reduction in the intake of
by L C Sharma
carbohydrates. Blanket preferences,
Facts For You
for instance, of wheat instead of rice,
April 1989 P 43-48
do not seem to have a scientific 41 Forests : Law versus Policy
basis. In a field that is rapidly evolving,
by Sharad Kulkarni
there is need for keeping abreast of
Economic & Political Weekly
April, 22,1989 P 859-862
the latest knowledge. Not only the
doctor, but also the nurses and 42 Satyagraha by Sardar Sarovar Oustees
by Mathew Kalathil
dieticians should know the rationale
Economic & Political Weekly
behind the choice of certain food
March 18, 1989 P 553-554
items.
43 A people's Dam
5 The family and friends must
by Anant R S Phadke
cooperate in helping the patient to
Economic & Political Weekly
April 22,1989 P 865
keep a proper diet and minimize
Stressful situations. They Should be 44 Balaipal Agitation : Socio-Economic
background
careful in not the patient to con
by Sujata Patel
sume food that is deleterious and
Economic & Political Weekly
even dangerous for him or her. They
March 25, 1989 P 604-605
should avoid coaxing the patient
saying: “A little sweet does not 45 Organic Farming ; An Alternative to
Pesticides
matter." The general public must be
by Ishwar Diatota
educated in discerning what is good
Health for the Millions
February 1989 P 17-19
for a diabetic and what is not. At
times, the doctor might have said 46 Bhopal: Settlement or Sellout?
by Indira Jaising
that a certain fruit is less harrrtful.
The Lawyers
From there people might conclude it
March 1989 P 4-6
is not harmful to take it in any
quantity. A third step would be to 47 The Bhopal Gas Leak Disaster and the
Supreme Court
further conclude that it is beneficial
by D N Sharaf
for a diabetic! Such misunderstandConsumer Confrontation

i>®

March - April 1989 P 6-11

HEALTH ACTION JUNE 1989 • 43

fc...
. •
______

- -

.

-

■ -v

•

MEDICAL ETHICS FORUM

EDICAtf
3SPITai I
60 034.

hploma

|ht to Health
Lobo, SJ

K.

A

'IISTRAIKX life/
-

uncem

!

ba ve questioned the
^of right to health as it seems
^possible to translate it in
terms. However, it must be
arm with 2
wjzed as one of the most basic
1., R.N.R.M.,^
Ewjortant human rights. Withice.
anizatd jSxnum degree of health, the
^6 of many other rights would
possible.
fjght to health exists, first of all, in
unation and -3 ■Rpfapeutic relationship. When a
admitted to a hospital, he
r^ehas a strict right to receive all
I jjtijealth care that is required in the
for Rs. 50/- dra^ BB'and is possible in the given
Jtumstances. Similarly, when a
Hpr.accepts to treat a patient,
Stotter has the right to receive the
iyable in Bangala ■Inattention the doctor can
st for applicatioBj W*de. The doctor would be
□hn’s Medical | peeled to have acquired the
560 034.
| gsite training, initial and conto keep abreast of the latest
’st for .
I (RPtoents
in his field according to
in which he is placed,
details:
necessary .treatment

9

■

that is concretely possible. The
patient also has the right to make
informed decisions regarding the
- i--- alterna
-ix.----.
course of treatment4. when
tives are available or iimportant
factors like cost, duration of
treatment and consequences are
involved. He has the right to be
treated as a person, confidentiality
and minimum privacy being res
pected.
2 It is more difficult to decide when a
hospital has the duty of admitting a
patient or the doctor accepting a
patient. Any discrimination on the
basis of such factors as caste would
be illegitimate. In an emergency,
there would be the clear duty of
admitting the patient when he or she
has no other place to go. But,
otherwise, in claiming a right, the
inherent limitations in time and
resources of the health care centre
or doctor have to be recognized. The
medical personnel have a right to

3 What about the right to health
care vis a vis society? According to
the Indian Constitution, the providing
of health care is a Directive Principle
of state policy (Part IV). While it is
not justiciable, public authorities
would be failing in their duty if they do
not allocate sufficient funds and
facilities for the basic health needs of
every citizen. It may be remarked in
passing that in the interpretation of
the so called Fundamental Rights in
Part III, the human right to health
care of all ought to be taken into
consideraion. When the State
cannot fully meet the minimum
health needs, the cooperation of
voluntary” agencies> should be enlisted.

Wour files____________

•ietec pplic

turn a new leaf in
ip

.
feralian
ent:
soccer dumped
its
Soccer
‘^“Sccornm
dumPed
,t 14-26,1989.'

shirts and track suits.
Officials said the deal had fewer
strings attached than the cigarette
sponsorship and means more funds

lth
Vth antnsmoking health
nber 13-25,anti-smoking

The foundation was set up in 1987

EMINARS fcnSorsh[

Igm S ton” mfcn’S

Hospital

their own rest, leisure and remune
ration. Special sense of dedication
may at times inspire greater generot^ which,
sj
sity,
which, ifif freely,
freely, manifested,
manifested,
would often bring in its own sense of
fulfillment.

Pr°mOt”n

iu"'°r

Mvr
■
Be fivp « u ,
dorian pl
set up by the
Promotion Founda;
ex*,
ends from the Socceroos
team to under-seven
^Wjx?ns' and ends a 15-year
fcku J1 niajor cigarette groups,
journalists.

tD distn bute the 23 million dollars
(19 million USS) garnered each year
■in the
■ ~
State of............Victoria from a levy on
tobacco Sales. (Reuter)
— The Indian Post

Wil1 mean s'9ns carrying
^all | Ssa9es at soccer grounds
? antk 6rs and officials wearing
k ^nioking quit’ symbol on

The Drugs Controller of India has
decided to ban the following drugs/
fixed dose combination after its
publication in the gazette.

i

n
,
.
Drugs banned

Fixed dose combination of tranqui
lizers (anxiolytic and neuroleptics]
with analgesic or antipyretic: fixed
dose combination of H2 Receptor
antagonist used in gastric and
deodenal ulcers, with other drugs:
formulation of essential oils contain
ing alcohol in excess of 12 per cent
V/V and use of chloroform in
pharmaceutical preparations.
Since the consumption of the
above drugs can be a health hazard,
the Commissioner, Food and Drug
Administration, has advised mem
bers of public, drug manufacturers,
distributors and retail chemists not
to produce or sell or use the above
drugs.
— The Hindu

______

--------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------

HEALTH ACTION MAY 1989»39

i‘- ■'i 't ~

'

1

I

I..-wia

X

"

■

■' 3lb:;

Rbk

JF"
_______:

MEDICAL ETHICS FORUM

-

Integrated
Healing Arts

in Agriculture
ations
lurthy
3/ Weekly
-P2651-26571

Dr JM Jussawaila

lefitted, Shah b J

INTEGRAIED

J

5-17

ioW\■t'C'®'-

of Pati ParmeshS
ir* Women
--3
Andrea Wolfe

'

a ’’”

New Dimension \

-xs
al Forestry

ir*r imp adtj

r

'.a! Weekly
|
P 2629-2630 |
tion Through Law]
e Measures

POPULAR PRAKASHAN

-Definitions of Death
Death has been traditionally
'
I.ilefined as the absence of two
mentand Ecdog<fynctjonSi of respiration and circula®on. Today more importance is given
i Rao
?a/ Weekly
‘ 'to the loss of the function of
988 PA 143- Integration by the controlling organ
S)f the body, namely, the brain with
I the central nervous system (DNS).
nic Issues ^E'ln a way the vital functions are
cy: a critique ■ (interdependent. The brain without
Kumar Singh ^circulation can survive only for 4
Wninutes and the heart without
35-37
^.Circulation guided by the CNS will
Water
'set
deteriorate
within 8 minutes,
^dowever,
fiuwever, today respiration and
: Circulationi can be maintained
17-19
Need
to
pWicially long after the brain has
sn Poor.
peased to function.
e
r
« brain death equal to personal death?
, A
k" the integrating function of the
1 Rights A Birds ^hole brain is totally lost, the human
P^anism would no longer be a
deal
Sectioning unity; it would be a dead
deal Weekly
Weekly
3 P 2679-2601 g^Janism even if certain isolated
snSUeS ar,d ce*ls wou^ continue for
L.016 time to show a residual life,
under
by Romila Suol P.rticularly
artificial
under
Emulation.
^Sorne would give much importance
the cortex which is related to
^nsciousness and thought and to
subcortical levels related to
ho ‘au tomat ic emotional function^9- ’f these regions of the brain stop
s Zoning they would conclude that
—-— —______

personal life ceases to exist and
human death may be declared.
However, all the regions of the brain
function as an integrated whole and
hence death may not be presumed
when some regions or even the brain
stem alone in still active. Besides,
present knowledge of the relation
ship between brain structures and
specific functions is still rudimentary.
Hence it is wiser if not necessary to
insist on at least the functional
destruction of the whole brain.
When is the brain dead?
The irreversible and total cessa
tion of the cerebral functioning of the
brain may be regarded as death.
Autopsy or removal of vital organs
for transplantation may then be
done.
There is need for caution in
interpreting a flat encephalogram in
certain cases such as that of infants,
deep hypothermia or strong barbitu
rate poisoning. In such cases the flat
recording may only be temporary.
Not irreversible Coma
Irreversible coma or 'persistent
vegetative state’ as such is not the
equivalent of death. Irreversible
coma means a state of unconscious
ness from which the still living
patient cannot be aroused. It should
be clearly noticed that dead person is
no longer in coma, and one who is in
coma is not yet dead!

35-C, Pandit Madan Mohan Malaviya
Marg
BOMBAY-400 034

Price: Rs. 25.00

Medicine, as other branches of
has made rapid progress in the last
few decades. It is unfortunate that it
has been at the cost of traditional
methods of healing. There has not
been any serious attempt to analyse
ancient knowledge and test its
effectiveness. Only now there is
growing realisation about the fact
that an effort should be made toward
studying the ancient healing arts and
make use of whatever is applicable.
Dr JM Jussawall.i author of
'Integrated Healing Arts — A New
Dimension and Revolution in Medi
cine ’ presents a brief summary of
various systems of medicine and
therapies hke ayurveda, homoeo
pathy, nature cure, bio-chemic
remedies, alternative medicine etc.
While introducing the book the
author rightly says, "One must
realise that there is much that is
good in all healing arts... and no one
system though reputed to be best
can be perfect or infallible.”
The book contains in brief the
various systems, their method of
application and use today. It provides
information about varied arts of
healing in ancient times.
HEALTH ACTION FEBRUARY 1989 • 41

..

MEDICAL ETHICS FORUM

sally usele$ .________ ____________________________
al) was hef

^□fHeSh^ledical Ethics Forum____________

* o The Ethical
iowhow, ChallcngE of AIDS
mean to
y. If the eno~_
Fr George Lobo s j
hatt is saidii |>
'ha
t to anythin^ut all wroff^
—
I was righi*^
e.
T
I he rapid spread of AIDS generously devote themselves to the
-A
/a/nAcquired Immune Deficiency Syn- care of these unfortunate people
Irome) has come upon the world as a deserve the greatest appreciation
najor scourge. While the ‘full blown' and support.
lisease almost always terminates in
Still, there is no doubt that the
i S Hospleath, for every such case there are scourge is a warning against sexual
e-560 009 >0 to 100 persons who are infected promiscuity and drug addiction. As a
, _. . md could pass on the disease.
victim of the disease put it: "It’s clear
.he Directof _L
, r
There is urgent need for alerting that Mother Nature doesn’t like us
15/^ie general population to the danger sleeping around. If you sleep around,
December if infection, but at the same time you get nasty diseases. It’s as simple
cular
voiding a scare which could cause as that."
nnecessary anxiety to people. The
nt of Inijpus js not spread by every day
It is not enough to say: "It is safest
. X.110114QCja| contact It is spread by semen, to stick to one partner". There is
id 3rd Novigginal secretions and blood. This need for marital commitment to
in the Gaztiainly happens through 1) sexual make sexual intercourse truly
>ited the mjtercourse, especially homosexual meaningful and to avoid the slippery
id their usefetivity; 2) by the use of contamina- path of sexual promiscuity. Again, to
5d syringes and needles by drug say "by taking a few precautions and
comk’
3) through transfusion of providing people with condoms (‘safe
js Wt anyfected
any’ecte d blood:
blood; 4) by an infected sex') people can continue to share
ether to her child.
loving relations." But what kind of
nal use.
combinati^° me have described the scourge relations? In the long run, the only
irol With ar?d''T6 retribution f°r promiscuous proper course is to restrict sexual
i
?d dlssolute living. However, this activity only between people joined
Jos not take into account the fact together by the sacred bond of
dng in the
many innocent people are marriage.
that they Bering from the disease. There
Promoting ’safer sex’ by the wide
cribing thelve even been a few cases of health distribution of condoms can create
he St. M3re workers contracting the virus dangerous illusions. The method
ary only, l^ogh contact with infected blood. does not provide sufficient safety.
nrrMliQ^i’
tbose who suffer from When condoms can fail to prevent
r C l)XmaJady deserve
deser,ve sympathy and conception which can take place only
*re, whar.pvpp
-.. ■____
atever mink*m*ght khave
been their during the limited fertile period of the
bit in t—
exposing themselves to it.
woman and the sperm can be more
e Officers Actually, the care of such easily blocked by the barrier, what is
Pharmacy atpm^i IS a 9reat challenge to the guarantee against the migration
th T l0VCG,,J:'UHId
'e and human solidarity. It of the dangerous AIDS virus and the
ed by
st tn
rnerr,hers who are the consequent infection?
oitaI.
to be Called uPon to relieve the
pt
strppjbe,caJled
The responsibility of not producing
Awards
3rkZr!
the victims. Health care infected offspring is best fulfilled by
erapy....!
avoiding conception whenever there
is serious danger of passing on the

infection. If the foetus is already
known to be or feared to be affected,
termination of the pregnancy would
not be justified. How can we solve the
problem of the unborn child by
putting an end to his/her life?
In order to help sufferers cope
with the fatal disease, there is need
for effective counselling services.
Society should strive to provide
them as far as possible. In this
connection we must stress the
importance of confidentiality. All
those who might have come to know
about the conditions in any other way
are also bound by strict confidentiaas the victims may suffer much
from the negative attitudes of
people. It should also be pointed out
that all should avoid judgemental
attitudes towards unfortunate
sufferers.

Of all the things you wear, your smile
is the most important.
l/l/e don ’t mind suffering in silence, if
everybody knows we're doing it.
A man shouldbe educated enough to
know that education alone is not
enough.
Ifyou want to relax, you have to work
at it.
Never worry about a competitor who
imitates you, because he can't pass
you while following in your tracks.
Winning isn't everything, but wanting
to win is.
— Arnold Palmer

(■'

HEALTH ACTION JANUARY 19P

MEDICAL NEWS

novocaine. The administration of
formalin caused necrosis (death of a
tissue). It was held that the Surgeon
was not liable as he could not have
discovered the mistake of the nurse
since there ws no visual change in
the solution given him for injection.
But the hospital was liable for the
negligence of the nurse.
4 Failure to take Precaution:
Every medical practitioner is
expected to take reasonable precautions in the treatment of his patients,
There are certain drugs and
injections which are known to cause
adverse reaction to certain types of
persons. Such drugs and injections
are to be administered only after a
test dose has been administered.
Otherwise the doctor can be held
laible for negligence.
5 Consent of the Patients:
In a surgical operation or in any
interference with the body of a
person the written consent of the
concerned person is necessary if
he/she is capable of giving it. If
unable to give such a consent,
someone competent to give it on
his/her behalf should be asked to do
so. If the Surgeon operates upon a
person without or against the
requisite consent he can be held
legally liable for negligence.
It may happen that a patient
refuses to give consent to an urgent
life-saving operation. In that case,
the doctor to protect himself, should
place on record the fact that the
patient had been requested to give
consent but had refused to do so. A
Kerala case (Dr. T.T. Thomas v. Elisa
AIR 1987 Ker. 52 Feb) illustrates
this point.
A patient came to the Surgeon
complaining of severe abdominal pain
which was diagnosed as a case of
appendicitis. The patient died owing
to the rupture of the diseased
appendix. The Surgeon (the defendent) pleaded that on the first day
the patient did not give his consent
to the operation and therefore he
could not perform* the operation on
that day. The case sheet of the
patient nowhere stated that the
patient ’s consent was sought and
was refused by him. In the
32 • HEALTH ACTION JANUARY 1989

I

circumstances the defendant was
held liable for negligence.
6 Failure to give honest advice:
A doctor can also be held legally
liable if owing to want of reasonable
skill and care, he fails to give an
advice or to undertake a treatment
which was necessary in the
circumstances. An honest doctor
must either personally consult or
refer his patient to a more
competent doctor if he himself can't
arrive at a reasonable degree of
certainty with regard to proper
diagnosis.
J The Operation Theatre:
A number of litigations emanate
from the operation theatre. These
cases mostly relate to negligence in
respect of activities connected with
the operative process. They include:
1 Unhygienic condition of the
theatre;
2 Negligence in the matter of
sterilisation
of instruments,
gowns, gloves, sheets, etc.;
3 Inadequate perparation of the
patient for operation:
4 Leaving sponges, forceps or other
instruments inside the patient ’s
body;
5 Burns or other injuries caused in
the course of operation or
treament.
Utmost care and precautions are
to be taken in the operation theatre
to safeguard the life and limb of the
patient. Any negligence of the doctor
or of the hospital management
leading to death or injury will attract
legal liability.
8 Post Operative Care:
After the operation, the hospital
authorities are expected to take
reasonable care of the patient. In an
English case, the plaintiff who was
suffering from an injury in the third
and fourth fingers was operated on
at the defendant’s hospital. After the
operation the plaintiff's hand and
forearm were bandaged up for two
weeks. During this time, the plaintiff
complained of pain but the Surgeon
took no action apart from giving
sedatives. When the bandages were
removed, all four fingers of the
plaintiff ’s hand were stiff and the

hand was practically usele<
defendant (hospital) was hej
for the negligence of the
[Cassidy v. Ministry of Healths edical
2 All E.R. 574).

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MEDICAL NEWS
i-----------------------------------------------

I

I IIIIMedical
I

»r

>r

0f I

negligence [

T Chacko

Every doctor who proposes to

practise medicine takes the Hippo
cratic oath binding him to observe
the code of ethics contained in it. This
is how the ancients thought to
ensure the highest standard from
the medical practitioners. But one
often comes across doctors who are
callous, greedy, and Unethical in their
. profession giving the impression that
they have taken a ‘hypocritic’ oath
instead of the hallowed 'Hippocratic'
oath. Many are the victims of such
medical practitioners, and the vast
majority of them are poor and
ignorant who suffer in silence. Do
they have any legal remedy against
the provable negligence of a medical
practitioner? Or what is the liability
of a doctor who causes death, or
' serious mental or physical injury to
the patient through his negligence?
< We shall examine,
k Medical negligence
A person who holds himself out as
a medical practitioner impliedly
•' I undertakes that he is possessed of
requisite skill
I the
the requisite
skill and
and knowledge
knowledge for
for
i the purpose. Such a person owes the
patient Certain duties, namely,
a a duty of care in deciding whether
to undertake a case or not;
a duty of care in deciding what
treatment to give;
c a duty of care in the administra
tion of that treatment;
d and a duty of care in answering
questions put to him by the
patient, in circumstances in which
he knows that the patient intends
to rely on his answer.
A breach of any of these duties will
sunnn >
T?
, uport*_ ani action for negligence by
tne patient.
• ------

t

r

9

t

Ib
■

A practitioner must possess a
reasonable degree of skill and
knowledge, and must exercise a
reasonable degree of care. A doctor
not t0 be
negl'9ent simply
uecausa something went wrong,
inspite of
Sometimes inspite
taking every
Sometimes
of taking
every
e Precaution things
- 5 go
9°
andJ
amiss in surgical operation
‘
medical treatment. He is liable only
when he falls below the standard of a
reasonably competent practitioner
in the field.
Types of medical negligence
Medical negligence may assume a
variety of forms. These include the
following:
1 Negligence in Diagnosis:
A proper diagnosis of the ailment
is the first duty of the medical
practitioner before he attempts to
treat the patient. A wrong diagnosis
leading to any injury to the patient
may invite liability in law.

2 Negligence in Diagnostic Aids:
Thorough investigation using
____
___means of diagnostic aids is
modern
almost a sine qua non for arriving ata !
properdiagnosis.Thisisaspecialised I
field and only competent persons .
must venture into it. If there is !
negligence on the part of the 1
consulting doctor to seek expert
advice in a given case, (e g
interpretation of an X-ray film) he
may be held liable.
3 Administration of Drugs and
Injections:
Doctors and nurses have been
held liable for the negligent
administration of a drug or injection
leading to death or injury to a patient.
_ A case from California (Helliman v.
Prindle (1963) 62 pa 2d 107]
illustrates the point, Through the
mistake of a nurse a solution of
formalin was injected into a patient
instead of the usual anaestic
HEALTH ACTION JANUARY 1989 • 31

MEDICAL ETHICS FORUM
By Fr. George Lobo, S.J.
Vatican Instruction on Care of Homo
sexual Persons
Homosexuality is one of the most
intriguing and difficult problems in mo
dern society. In discussing it, we should
carefully note the difference
between
homosexual tendency and overt homo
sexual activity. Regarding the first, we
have true homosexuality when there is
exclusive attraction to persons of the same
sex, while homosexuality in the broad
sense implies sexual attraction to either
sex which is also called bisexuality. For
reasons that are not entirely clear, there
seems to be an increasing incidence of
true homosexuality. This is particularly
so in some North European countries.

■

Until recently,
especially in
the
Anglo-Saxon world, a person with a homo
sexual orientation was looked upon as a
pervert. Any homosexual action
even
between consenting adults in private was
considered as a crime to be severely
punished by law. This gave rise to a lot
of persecution and blackmail.
Hence,
naturally, there was a strong reaction
with thousands of homosexuals 'coming
out into the open' and grouping them
selves into 'gay' clubs and associations.
There was a veritable 'homosexual move
ment' defending the right of homosexuals
to freely act according to their sexual
orientation. Such activity was sought to
be defended not only from the arm of
the law, but was held right in conscience.
The many structures against homosexual
activity in the Scriptures
(e.g..
Lev.
18:22; 20, 13; Rom 1:18-32) were sought
to be explained away in various ways.
April 1987

;•
|

I

It is against such excesses that the
Holy See has issued an Instruction on 1
October 1986. This is in line with the
treatment of the subject in the Vatican
Declaration on Certain Questions concern
ing Sexual Ethics" of 29 December 1975.
The homosexual condition as such,
although not a sin in itself, is said to be
"a more or less strong tendency ordered
towards an intrinsic moral evil; and thus
the inclination itself must be seen as an
objective disorder." (N. 3). Hence the
living out of the orientation in homosexual
activity is not a morally acceptable option.
The document insists that it is only
in the marital relationship that the use of
the sexual faculty can be morally good.
"To choose someone of the same sex for
one's sexual activity is to annul the rich
symbolism and meaning, not to mention
the goals, of the Creator's sexual design."
(N. 7). Those who reject this teaching of
"if not
the Church are said to reflect
entirely
consciously,
a
materialistic
ideology which denies the transcendent
vocation of every individual." (N. 8).
While maintaining this stand,
stand. the
document says: "It is deplorable that
homosexual persons have been and are
the object of violent malice in speech or
in action." (N. 10). The persons concerned need understanding and compa
ssion. However, this should not lead to
the claim that the homosexual condition
is not disordered. It cannot be said that
because it may not .be the result of deli
berate choice, the homosexual person
would have no other alternative but to

29

behave in a homosexual fashion (N. 10).
Neither is it true that sexual behaviour of
homosexual persons is always and totally
compulsive and
therefore
inculpable
(N. 11).
Homosexual persons are asked to
respect the will of God in their life by
accepting their sufferings and difficulties
in union with the sacrifice of the Cross.
They are called to live a chaste life using
the means of grace like the sacrament of
Reconciliation (N. 12).
The document makes an important
point when it notes that a human person
cannot be adequately described by a
'reductionist reference' to his or her sexual
orientation. '"Every person has a funda
mental identity: the creature of God, and

by grace. His child and heir to eternal life'".
(N. 16).
While the Bishops are to defend this
teaching, they are also asked "to support,
with the means at their disposal, the
development of appropriate forms of pasto
ral care for homosexual persons. They
would include the assistance of the psy
chological,
sociological
and
medical
sciences." (N. 17).
There is need for a more thorouhgoing
study of the causes of the homosexual
orientation or sexual inversion, and the
development of more effective forms of
therapy in order to bring about the reori
entation of the libido. Meanwhile, homo
sexual persons should be helped to- cope
with their problem, in among other ways,
by sublimating their sexual energy.

NEW VACCINES
Work is in progress on four of the vaccines currently used in the EPI: whooping
cough, measles, polio and BCG. Whooping cough vaccine, while still ten times
or more safer than the disease, still causes an unsatisfactory number of side-reactions.
One in about every 300,000 immunizations results in lasting neurological damage.
New purified vaccines, developed initially in Japan, promise fewer reactions. They
are currently undergoing field trials in Sweden.
Because of interference from antibodies transferred by the mother, measles vaccina
tion must be delayed for at least nine months after birth. This varies from nine
months in developing countries to 12 to 15 months in industrialised countries. But
recent observations have suggested that one particular strain of measles vaccine may
protect children from four to six months of age. This would be a boon to alLcountries, and field trials to confirm these observations are already under way.

I

*:

Two excellent polio vaccines are available. The one in most common use is the
oral (Sabin) vaccine. An inactivated vaccine (Salk) is also highly effective. The
Sabin vaccine, however, is associated with paralysis in about one in a million vaccinees. In communities with low or moderate immunization coverage, the Salk
vaccine may be less effective in controlling polio than the Sabin vaccine, and is several
times more expensive. It may very soon be possible to synthesise a new vaccine
which will be devoid of paralytic side-effects.

I”

30

£

Medical Service

1

f
1

Medical Ethics Forum - 48
By Fr. Gecrge Lobo S.J.

GUIDANCE OF THE CHURCH ON
MEDICAL ETHICS

Primacy of Conscience and Need of Forming
It Rightly

Instead of dealing with a specific issue,
this item of our Forum will present the
guidelines of the Church regarding Medical
Ethics.

“Man has in his heart a law written by
God. To obey it is the very dignity of man;
according to it he will be judged
The more a correct conscience holds sway,
the more persons and groups turn aside
from blind choice and strive to be guided
by objective norms of morality.” (Gaudium
et Spes, N. 16).

No Conflict between Science land Faith

“If methodological investigation with
in every branch of learning is carried out
in a genuinely scientific manner and in
accordance with moral norms, it never
conflicts with faith.” Vat. II, Gaudium et
Spes, 36).
Need for Ethics in Medical Science
“Science and technology require, for
their own intrinsic meaning, an uncondi
tional respect for the fundamental criterion
of the moral law! that is to say, they must
be at the service of the human person, of
his inalienable rights and his true and
integral good according to the design and
will of God.” (Cong, for the Doctrine of
the Faith, Respect for Human Life in Its
Origins, 22 Feb. 1987. Introduction, N. 2).

Moral Criterion for Medical Intervention

“The moral aspect of any procedure
does not depend solely on sincere intentions
or on an evaluation of motives. It must
be determined by objective standards, These
(are) based on the nature of the human
person and his acts.” (Gaudium et Spes,
N. 51).
12

Role of the Church

“In the formation of their conscience,
the Christian faithful ought carefully to
attend to the certain doctrine of the Church
......... It is her duty to declare and confirm
by her authority the principles of the mcral
order which have their origin in human
nature itself.” Vat. II, Dignitatis Humanae, N. 14).
Dignity of the Human Body
The humsn body is, in its own right,
God’s masterpiece in the order of visible
creation. The Lord has intended that it
should flourish here below and enjoy immor
tality in the glory of heaven.” (Pius XII
to Sporting Associations. 20 May, 1954).
“Blessed is your devotion, which sees
the living temple of the Holy Spi it in these
bodies reduced by illness, disfigured by
injury and paralysed by infirmity. ” (Pius
XII to Doctors and Nurses, 6 Sept. 19500).
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I

Mission of the Doctor

“The doctor has been appointed by God
himself to minister to the needs of suffer
ing humanity. He who created that feverconsumed or mangled frame, now in your
hands, who loves it with an eternal love,
confides in you the noble charge of restor
ing it to health. You will bring to the sick
room and to the operating table some
thing of the charity of God, of the love
and tenderness of Christ, the Master phy
sician of soul and body.” (Pius XII to
Doctors, 13 Feb. 1945).
Qualities of Nurses

I

II

She must possess “an unassuming,
sensitive and fine tact, wzhich can under
stand the sufferings of the sick and forestall
their needs, which can distinguish what
can be said from what is better left unsaid;
tactful too, in the relations with the doctor,
and with fellow nurses.” (Pius XII to
Nurses, 21 May, 1952).

Right to Health and Health Care
“Every man has the right to life and
to bodily integrity, and to the means which
are necessary and suitable for the proper
development of life. These means are
primarily food, clothing, shelter, rest, medi
cal care, and finally the necessary social
services.” (John XXIII. Pacem in Terris,
11 April 1963, N. 11).

*

Inviolability of Human Life

“Every human being, even a child in
the mother’s womb, has the right to life
directly from God and not from the parents
or from any human activity. Hence there
is no human authority, no science, no med
ical, eugenic, social, economic, or moral
‘indication’ that can offer or produce a
September 1987

valid juridical title to a direct, deliberate
disposal of an innocent human life.” (Pius
XII to Midwives, 29 Oct., 1951).
“Human life is the basis of all values;
it is the source and indispensable condition
for every human activity and all society
......... it is a loving gift from God, which
they must preserve and render fruitful ....
.... Hence no one may attack the life of
an innocent person without thereby resist
ing the love of God for that person; with
out violating a fundamental right which
can be neither lost nor alienated and, there
fore, without committing an extremely serious
crime.” (Cong, for the Doctrine of the
Faith, on Euthanasia, 5 May 1980).
Malice of Suicide

“Intentional death or suicide is just as
wrong as is homicide. Such an action by
a human being must be regarded as a reje
ction of God’s authority and loving plan.
In addition, suicide is often a rejection of
love for oneself, a denial of the natural in
stinct to live and a flight from the duties
of justice and charity one owes one’s neigh
bours or various communities or human
society as a whole. At times, however, as
everyone realizes, psychological factors may
lessen or even completely eliminate res
ponsibility.” (ibid.').
Euthanasia
“Euthanasia here means an action or
omission that by its nature or by intention
causes death with the purpose of putting
an end to all suffering..........No one may
ask for such a death dealing action for one
self or for another for whom one is responsi
ble, nor may one explicitly or implicitly
consent to such an action. Nor may any
authority legitimately command or permit
it. For such an action is a violation of the
13

divine law, an offense against the dignity
of the human person, a crime against life
and an attack on the human race.” (ibid)..
“The pleas of the very seriously ill as
they beg at times to be put to death are
hardly to be understood as conveying a real
desire for euthanasia. They are almost
always anguished pleas for help and love. ”
(ibid.)
Use of Painkillers in Terminal Illness
Is the removal of pain and conscious
ness by means of narcotics.......... permitted
by religion and morality to both doctor and
patient even at the approach of death and
if one foresees that the use of narcotics
will shorten life? Yes - provided that no
other means exists and if, in the given cir
cumstances, the action does not prevent
the carrying out of other moral and religi
ous duties. (Pius XII to Anesthesiogists,
24 Feb. 1957).
Ordinary and Extraordinary Means for Life
and Health

‘ Normally one is held to use only
ordinary means - according to circumstances
of persons, places and times and culturethat is to say, means that do not involve
any grave burden for oneself or another.”
(ibid.')
“It is always licit to be content with
the ordinary remedies which medical science
can supply. Therefore, no one may be
obliged to submit to a type of cure, which
though already in use, is not without risks
or is excessively burdensome .......... When
death is imminent and cannot be prevented
by the remedies used, it is licit in conscience
to renounce treatments that only yield a
precarious and painful prolongation of
life. At the same time, however, ordinary
treatment that is due to the sick in such
14

cases may not be interrupted.” (on Euthan
asia).

The document also speaks of ‘proporti
onate’ and ’disproportionate’ means.
Accepting Death

“It is necessary, therefore, that we,
without in any way hastening the hour of
death, should be able to accept it with full
responsibility and dignity. It is true that
death marks the end of our earthly existence,
but at the same time it opens the door to
immortal life. Therefore, all-must prepare
themselves for this event in the light of
human values, and Christians more so in
the light of faith.” (on Euthanasia).

I

Respecting Unborn Human Life and
Abortion

From the moment of its conception
life must be guarded with the greatest care,
while abortion and infanticide are unspea
kable crimes.” (Gaudium et Spes, N. 51).
“The right to life is no less to be res
pected in the small infant just born than
in the mature person. In reality, respect
for human life is called for from the time
that the process of generation begins. From
the time that the ovum is fertilized, a life
is begun which is neither that of the father
nor of the mother; it is rather that of a new
human being with its own growth. It
would never be made human if it were not
human already.” (Cong, for the Doctrine
of the Faith, on Procured Abortion. 28 June
1974, N. 12).
I

“This Declaration expressly leaves aside
the question of the moment when the spiri
tual soul is infused .......... It is a philoso
phical problem frem which ovf moral
affirmation remains independent for two
reasons : 1) supposing a belated animation.
Medical Service

there is still nothing less than a human life,
preparing for and calling for a soul in which
the nature received from the parents is
completed; 2) on the other hand it suffices
that this presence of the soul be probable
(and one can never prove the contrary)
in order that the taking of life involve accep
ting the risk of killing a man, not only
waiting for, but already in possession of
his soul. ” (ibid, footnote 19).

“One can never approve of abortion;
but it is above all necessary to combat its
causes:" (ibid.. No. 26).
Responsible Parenthood
In relation to physical, economic,
psycnological and social conditions, res
ponsible parenthood is exercised, either by
the deliberate and generous decision to
raise a numerous family, or by the decisi
on, made for grave reasons and with due
respect for the moral law, to avoid for the
time being, or even for an indeterminate
period, a new birth.” (Paul VI, Humanae
Vitae, 25 July 1968).

I

“This Council realises that certain
modern conditions often keep couples from
arranging their married lives harmoniously,
and they find themselves in circumstances
where at least temporarily the size of the
ir families should not be increased. As a
result, the faithful exercise of their love and
the intimacy of their married lives are hard
to maintain. But where the intimacy of
married life is broken off, it is not rare for
its faithfulness to be imperiled and its
quality of fruitfulness ruined .......... (How
ever), sons of the Church may not under
take methods of regulating procreation
which are found blameworthy by the teach
ing authority of the Church in its unfold
ing of the divine law.” (Gaudium et Spes.
N. 51).
September 1987

“A reciprocal act of love, which jeo
pardizes the responsibility to transmit life
which God the Creator, according to parti
cular laws, inserted therein, is in contra
diction with the design constitutive of
marriage, and with the will of the Author
of life.” (Humane Vitae, N. 13).
“The direct interruption of the genera
tive process already begun, and, above all,
directly willed and procured abortion, even
if for therapeutic reasons, are to be absolu
tely excluded as licit means of regulating
births .......... Equally to be excluded is
direct sterilization, whether perpetual or
temporary, whether of the man or the
woman. Similarly excluded is every action
which, either in anticipation of the conju
gal act, or in its accomplishment, or in the
development of its natural consequences,
proposes, whether as an end or as a means,
to render procreation impossible ” (ibid.,
N 13).
“If, then, there are serious motives to
space our births, which derive from the
physical or psychological conditions of
husband and wife, or from external condi
tions, the Church teaches that it is then
licit to take into account the natural rhy
thms immanent in the generative functions,
for the use of marriage in the infecund peri
ods only, and in this way to regulate birth
without offending the moral principles which
have been recalled earlier.” (ibid. N. 16).

Heterologous Artificial Fertilization
This “is contrary to the unity of marri
age, to the dignity of the spouses, to the
vocation proper to parents, and to the
child’s right to be conceived and brought
into the world in majriage and from marri‘
age.” (on Respect for Human Life in its
Origins (N. II, B, 2).
15

-I

Homologous Artificial Fertilization
Homologous ‘in vitro’ fertilization is
neither in fact achieved nor positively willed
as the expression and fruit of a specific act
of conjugal union. In homologous IVF
and ET (embryo transfer), even if it is con
sidered in the context of ‘de facto’ existing
sexual relations, the generation of the
human person is objectively deprived of its
proper perfection: namely, that of being
the result and fruit of a conjugal act in
which the spouses become ‘cooperators
with God for giving life to a new person’.”
(ibdi., II B. 5.)
Even mere "homologus artificial inse
mination within marriage cannot be admitted
except for those cases in which the mechani
cal means is not a substitute for the conju
gal act but serves to facilitate and to help
so that the act attains its natural purpose.”
(ibid.).
“Artificial insemination as a substitute
for the conjugal act is prohibited by reason
of the voluntarily achieved dissociation of
the two meanings of the conjugal act.
Masturbation, through which the sperm
is normally obtained is another sign of this
dissociation: even when it is done for the
purpose of procreation, the act remains
deprived of its unitive meaning.” (ibid.).
Respect for Human Embryos

“If prenatal diagnosis respects the life
and integrity of the embryo and the human
foetus and is directed towards its safe
guarding or healing as an individual, then
it is lieit ” (ibid. I, 2).
“Medical research must refrain from
operations on live embryos, unless there is a
moral certainty of not causing harm to the
life or integrity of the unborn child and the
16

mother, and on condition that the parents
have given their free and informed consent
to the procedure. ” (ibid., I. 4).
“If the embryos are living, whether
viable or not, they must be resepcted just
like any other human person; experi
mentation on embryos which is not directly
therapeutic is illicit.” (ibid.).
“It is not in conformity with the moral
law deliberately to expose to death human
embryos obtained “in vitro”. In conse
quence of the fact that they have been pro
duced in ‘in vitro ’ those embryos which are
not transferred into the body of the mother
and are called ’spare’ are exposed to an
absurd fate, with no possibility of their
being offered safe means of survival which
(ibid. I, 5).
can be licitly pursued.”
Genetic Engineering
“Certain attempts of influence chromosomic or genetic inheritance are not therape
utic but are aimed at producing human
beings selected according to sex or other
predetermined qualities. These manipula
tions are contrary to the personal dignity
of the human being and his or her integirty
and identity.” (ibid., I, 6).
Ethics of Surgery

“In virtue of the principle of totality
of his right to employ the services of the
organism as a whole, he can give indivi
dual parts to destruction or mutilation when
and to the extent that is necessary for
tie good of his being as a whole, to assure
its existence or to avoid, and naturally to
repair, grave and lasting damage which
could otherwise be neither avoided nor
repaired.” Pius XII, to Histopathologists,
13 Sept. 1952).
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4

“Three conditions govern the moral
licitness of a surgical operation, which
causes anatomic or functional mutilation:
first that the continued presence or function
ing of a particular organ within the whole
organism is causing serious damage or
constitutes a menace to it; next, this
damage must be remediable or at least
measurably lessened by the mutilation in
question, and the operation’s efficacy in
this regard should be well assured; finally,
one must be reasonably certain that the
negative effect, that is, the mutilation and
its consequences, will be compensated for
by the positive effect: elimination of danger
to the whole organism, easing of pain,
and so forth”
(Pius XII, to Congress of
Urology, 8 Oct. 1953).

total exclusion of all danger cannot be
demanded. This is beyond all possibilities
of human nature, and would paralyze all
scientific research and would very cften
turn to the detriment of the patient.” (Pius
XII, to Congress of World Medical Assccia
tion. 30 Sept. 1954).
Need for Consent of Patient
As a private person, the doctor can take
no measure or try no course of action without
the consent of the patient. The doctor has
no other rights or power over the patient
than those which the latter has given him
explicitly or implicitly or tacitly.” (Pius
XII to Histopathologists").

Confidentiality
Experimentation for Benefit of Others
The doctor “has no right to permit
scientific or practical experiments which
entail serious injury or which threaten to
impair his health to be performed on his
person, and even to a lesser extent is he
authorized to attempt an operation of ex
perimental nature which according to autho
ritative opinion, could conceivably result in
mutilation or even suicide. ” However, ’’the

“These norms (of Christian ethics),
in fact, while they clearly affirm the obliga
tion on the physician to preserve the profe
ssional secret, above all in the interest of
the common good, do not concede to this
an absolute value. For that very common
good would suffer were the professional
secret placed at the service of crime or
injustice” (Pius XII to Italian MedicalB’iological Union, 12 Nov. 1944).

FROM OUR PRESS CLIPPINGS FILE

Genetic clue to heart disease
Atherosclerosis, the most important
cause of coronary diseases today, may be
the result of a genetic mutation, a University
of Wisconsin study claimed recently. Profe
ssors K M Taylor and J Rapacz found that
this mutation affects the proteins which can
alter the level of cholesterol in blood. They
conducted a detailed analysis of coronary
disease with raised serum cholesterol in
nearly 14,000 pigs after it was discovered
September 1987

that, under a microscope, the disease
tissue closely resembles that in human
beings.
A significant number of the animals
had early signs of atherosclerosis even when
they were given a low-fat diet. The mutant
pigs died before reaching the age of 4 years,
while normal pigs lived thrice as long.

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Indian Express 7-7-1987
17

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ETHICS

-

II [Vledical Ethics Forum - 5
fr George Lobo sj

5'

Ethical Dimensions
I of Nutrition

f

In the present social system, there

is overconsumption by the rich and
under-nutrition for the poor. The rich
and middle classes suffer from ail
ments like obesity, high blood pres
Z; sure, cardiac diseases and diabetes.
The poor masses are afflicted by dis
eases related to malnourishment.
The rich use alcohol excessively to
£ relieve their tensions, and the poor to
calm their hunger. To face this dual
problem, the prevailing unjust sys
tem needs to be modified.
Health professionals do not seem
to be sufficiently aware of the prime
importance of proper nutrition for
maintaining health. An enormous
amount of energy and money is
g. -expended on other areas, but this
I basic need is relatively neglected.
Hospital administrators have to ask
whether The patients are getting
proper diet either from the institu
tion or from the home. Are the
patients discharged with better
knowledge of nutrition to maintain
their health? Do diabetics get ade
quate instruction on diet apart from
being supplied with a list or summary
saying ‘this is to be avoided’ or ‘that
can be taken’?
Nutritional instruction in schools is
Qrossly inadequate. There is practicaliy nothing on proper preparation of
cod to maximize its nutritional value.
. nings like the advantage of sprout,n9 seeds are scarcely touched on.
Fruits are exported in such large
quantities to the cities or to other
untries that the families who prop Ce ^em often do not get anything.
or children in the villages are now
Pnved of the traditional source of
mins and minerals.

I

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redi 6 neW WaVs °f food processing
Ce its nutritional value. The addi-

tives which are used are often dan
gerous to health. There is a strange
craze for refined sugar or polished
cereals which have much diminished
nutritional value, f
' '
Although
refined sugar is known to cause
decalcification of teeth and to have
high correlation with diabetes, it is
becoming increasingly unfashionable
to use better substitutes like gur or
jaggery. The increasing price of
refined sugar gets too much prominence in the media as if it is an un
mitigated evil.
There is widespread adulteration
in such items as ghee and edible oils.
Dangerous articles like kesari dal are
pushed by the traders to make a
profit at the expense of the health of
poor people.
The increasing attraction for
tonics and baby foods seriously
depletes the capacity of people to
buy sufficient food. The disadvantages of artificial feeding compared
to breast feeding are now well known
but the unhealthy trend goes on.

Health professionals do
not seem to be sufficiently
aware of the prime impor
tance of proper nutrition
for maintaining health. An
enormous amount of en
ergy and money is expen
ded on other areas, but
this basic need is relatively
neglected.

There is some basis for traditional
food preferences and avoidance.
However, many local beliefs and
taboos are unscientific and ne^
serious and open discussion. The
should be readiness to change when
needed. Religious prescriptions are
often cultural taboos wtjich through
the ages have received
religious
'0(
sanction. True religion requires an
unprejudiced examination of their
real value,
Some of the best lands in the
country are diverted to tobacco
(if not poppy) cultivation. This may
bring some immediate gain to the
growers, traders or the excise
,
___ ____
department.
But it is a drain on the
resources of the land and a cause of
diseases related to tobacco consumption. There is need for an economic reform that will give priority to
the growing of food crops with high
nutritional value.
Growing of vegetables is neglect
even when there are facilities for it.
There is need for bringing about
increased awareness about the
nutritional value of vegetables and an
economical way of growing them.
Again it should not happen that the
grower gets no benefit from them.
Finally we should realize that nutri
tion is not merely a question of
acquiring some knowledge and giving
some brief instructions to people
whether in health or sickness. Many
deep attitudes have- to be changed
and social structures have to be
modified. This calls for a concerted
effort on the part of health profes
sionals in collaboration with other
people.
I —
It is difficult to reconcile the religious
creed of some people with their
greed.
HEALTH ACTION

SEPTEMBER 198B • 45

■■'

"i
—
MEDICAL ETHICS |

.7
of the
of
g urib
One Ul
consequences
y
LI IC LUI
lot
unou
? O mechanization of health
' ■) Co.
carec is that
initiative in drug development has
-’
passed from the medical profession
rn the pharmaceutical industry. Trav?; ditionally pharmacy was sub-ordinate
A <' to the physician. Now the physician is
constrained to perform the pharma
cological task assigned them by the
drug industry. The inadequate phar
macological education of the medical
school graduate does not provide the
background to examine critically the
claims of the industry for its pro
ducts. Even research is often influ
irichenced by the interests of the drug
■ne a
industry. Medical journals become
the vehicle of promoting the same
Henainterests. Companies use them as
onial■
advertising media carry over-whelmcious
‘ ‘ff- ing the physician not only with publicalism,
ity, but also with article after article
thing
on the product that is being pro
I and
moted at the time. Thus they hinder
laws
iicine ■ w legitimate scientific enquiry by plac
ing articles designed to reflect indus
< r'.
with
try views.
sys10 Bourgeois competitive values
e the
induce the physicians to seek the
; allomaximum advantage. Not only are
icritithey misinformed by cleverly/ Pre
2dies. ■
rn life J Iw pared and attractively got up bro
chures regarding the efficacy of the
push
drugs, but they are influenced by
■nbel■
Physician samples, (often sold), and
g for
other forms of inducements like
'
□ pay
Wj pens, diaries and even conference
attendance costs. It is indeed a sad
ievefact that the continuing education of
Itinadoctors is largely carried on by medi
n the
cal representatives and their infor
' nefmation material containing a lot of
Dnals
half-truths. Besides, an undue desire
even
|
for gain leads the physician to neg
'ests
lect the pin pointing of the disease
fherand to prefer ‘fixed combination’ anti
i the
biotics and ‘broad spectrum’ drugs
that
to take care of multiple eventualities
inef-.
and thus be able to process a large
jnity.
number of cases during a working
■tified
nay. Thus there is an unhealthy and in
‘biomany ways corrupt relationship
ulatbetween the medical profession and
'? ■ b
Irugs
the drug industry.
an be
11 On the other hand, research on
sible
me therapeutic value of medicinal
:e of
herbs and roots, presented in some
sent
rare journals, collects dust in refer
to all
ence libraries. However, fortunately,
tes
the healing value of non drug theraP’es like Yoga, Pranayama, Medita-

1 *

’-^1

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tion and Accupuncture is being
increasingly recognized. Strangely,
these are being patronized more by
the well-to-do than the poor.
12 The technological and manipul
ative mentality is a block against the
promotion of preventive health. It is
yet to be fully realized that clean
water is much more importaht than
anti-biotics, wholesome food than
vitamin pills, vaccination than expen
sive drugs or gadgets.
13 The technological mentality
also leads to the transgression of
the legitimate bounds of human
experimentation. It is not permissible
to use a drug unless it has been suffi
ciently tested in the laboratory and
on animals. Further, an experimental
drug may not be used when a cer
tainly effective remedy is available,
the risk is proportionately tolerable
and there is at least the reasonably
presumed consent of the patient.
The practice of trying out experi
mental drugs on patients in poorer
countries is to be condemned as a
grave offence against humanity.4

■

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The Remedy
The very exposition of these evils
regarding drug prescription sug
gests a programme to combat them.
However, some of these will be here
briefly mentioned.
1 There is need of evolving a more
humane and person-centred
approach to health care. This should
above all seek the true interests of
the patients. For this the time
honoured principles of totality and of
double effect must be clearly under
stood and applied.
2 The physician must regain the
autonomy and ideals of his noble
profession.
3 Cultural alienation and political
interference of foreign powers must
be unmasked and vigorously
countered.
4 There is need for counteracting
the pernicious aspects of material
ism and capitalism.
5 There should be a massive
movement against the manipulation
of drug companies. While the more
immediate perspective of abuses in
the field of drugs must be attended
to the deeper political and cultural

roots of the problem need to be
tackled.
6 The well-intentioned efforts c
the government to check the abusec
in the production, distribution anc
use of drugs need to be supported.
7 Especially urgent} is the effort tc
reduce prescription to roughly 20C
essential drugs (WHO estimate,
with generic names so that low cost
efficient and safe drugs are available
to everyone.
1 See Willaim Barett The Illusion o
Technique, Garden City, N.Y. Ar^cr
Press. 1978.
2 For Clinical Iatrogenesis and the
Medicalization of life, see Ivan lllicr
Limits to Medicine, Calcutta, Pupa
1977.
3 Concerning the modern tendenc
to manipulate human beings, se:Bernard Haring, Manipulation, Sloug:
St. Paul Publications, 1975.
4 For a more complete treatment or
ethical principles regarding Medical
Experimentation, see my book, Cur
rent Problems in Medical Ethics, 3rd
ed„ 1980. pp. 100-105.

Being Helpful
Sign in a restaurant: “If you want tc
put your ashes and cigarette butts in
your cup and saucer, let the wai^ss
know and she will serve you you jffee in an ashtray. ’’
Confucius No Say
Men who leave home to set world
on fire often come back for more
matches.

• Men who have home to set world
on fire often come back for more
matches.
• When man works like horse,
every-body ride him.
• Man who beef too much find him
self in stew.
We still can’t understand how
rumours without a leg to stand on
can get around so fast.

Medicine has advanced so much in
recent years that it is almost impos
sible now for a doctor to find anything
all right about a person.
'
HEALTH ACTION AUGUST 1988 • 43

MEDICAL ETHICS

Ethical Problems
of Drug
Prescription
Fr George Lobo sj
! Drugs are supposed to be pres

efficacy of bio-chemistry. The con
centration is on artificial labels of
cribed for healing or beneficent pur
sickness to be treated by mechanical
pose. But the harm done to the
means. The value-free or value
patient by the increasing over
neutral model of science derived
pricing, over-prescribing and misfrom physics and chemistry is quite
pr^scribing of drugs is becoming
appropriate when it strictly confines
j r
ifest. The purpose of this short
itself to these disciplines. But it
paper is to uncover the reasons
acquires a dangerous tone when the
behind this unfortunate situation so
manipulation freely extends to the
that effective remedies may be found
sphere of human life. Man the manip
to tackle it.
ulator ultimately ends up being man
1 Modern life is being increasingly
regulated by the technological the manipulated. Human interven
tion, instead of serving the true
model Instead of technology being
interests of man, tends the violation
at the service of man, man is being
of basic human values and rights.
ruled by technology. The technical
4 TJie primitive witch doctor
order, in the first flush of its success,
sought to create an air of mystifica
is entering into every nook and crany
tion by his magical incantations. The
of our life and seems to brook no
modern therapist creates a similar
inherent limitations. Thus human
existence seems to be moving from effect by prescribing exotic drugs
______ ________
i qualitative
progress to mere . quan- with esoteric names and whose
I
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.
I ■
I . I. _ _
titative development which has little, action he Hfr’nseS scarcely under
stands.
use for basic human values that can
not be measured on the quantitative
5 Modern life tends to reduce the
scale of external results.
capacity of man to cope with pain and
other forms of distress. Hence the
2 This has an effect on the underdesire for quick relief. The patient
nding of health, disease and heali mg. Instantaneous cure of the symp- Fooks for magical results and seeks
out those who will provide them. The
toms is becoming the goal of medical
procedures. The search is for physician is tempted to yield to this
wonder drugs which can provide irrational urge without paying suffiquick relief, but leaving the underlying
cient attention-to the long term conThere is thus a vicious
cause of the disease untouched or sequences. ’T’’
even aggravating it. The apparent circle of mutual manipulation which
efficacy of drugs leaves behind a host diminishes the humanity of the
patient as well as the medical
of what are called ‘side effects’ when
practitioner.
often they become the malignant
‘main effects’. Thus we have an
6 The capitalist system with its
increasing number of ‘iatrogenetic’- insistence on the 'profit motive’ and
(doctor induced) diseases1.
'free enterprise’ leads the multina3 The personal mode! of healing is tionals and local big firms to exploit
being replaced by the manipulation of the consumer without caring for his
the patients3. Instead of personal dia- true interests. While the pharma
logue concerning the deeper cause of ceutical industry is meant to cater to
the distress, trust is placed on the the health needs of the people, the
42 • HEALTH ACTION AUGUST 1988

people become means of easy enrich
ment. Human persons become a
means instead of being an end.
7 The deep rooted cultural aliena
tion, which is an aftermath of colonial
ism and one of the more pernicious
manifestations of neocolonialism,
produces a glamour for everything
that is foreign. The educated and
even the neoliterate regard with awe
the modern system of medicine
because of its alien origin and with
diffidence, if not contempt, at sys
tems that are indigenous. Hence the
uncritical acceptance of potent allo
pathic drugs and the equally uncriti
cal rejection of local remedies.
Superficial fascination for modern life
enables drug companies to push
their products by cosmetic embel
lishment and elegant packing for
which the poor consumer has to pay
heavily.
8 The dependent status of deve
loping countries enables the multina
tionals to put undue pressure on the
local authorities to permit their nef
arious activities. The multinationals
find a ready ally in local big firms even
when their commercial interests
may to a certain extent clash. Ther
eby, drugs that are unproved in the
country of origin or even those that
have been proved dangerous or inef
fective can be pushed with impunity.
The whole matter can be mystified
by false claims like of special ‘bio
availability’. Any attempt at regulating the distribution and use of drugs
or of banning dangerous ones can be
countered by visible and invisible
connivance of
pressures with the ____'.-------alienated specialists. The present
craze for uncritical opposition to all
governmental policies contributes
to governmental inaction.

9 0
mecha
initial'
passet
to the
ditiona
to the
const!
cologi'
drug ir
macol
schoc
backg
claims
ducts
encec
Indus
the v
intere
’ adver
ing tb
ity, b>
on ti
mote
legiti
ingai
try v
1C
indue
max'
they
pare
chur
druc
phy?
othe
pen
attE
fact
doc
cal
| ma’
half
for
ec’
anc
bio
to*
anc
nur
da'
me
‘X :
be
thf

Xr-.

■0

th
he
ra
er
th
pii

MEDICAL ETHICS

Medical Ethics Forum
Tfe
:</• Artificial Hydration and Nutrition

Fr GEORGE LOBO, S.J.

q.

How far is it obligatory to
f-Trs;< continue
with
Intravenous,
Naso-Gastric or other forms of
Artificial Hydration and Nutrition
(ANIN) in terminal illness?
■ B. The basic principles for the
- •
normal obligation are detailed in
the
Vatican
Declaration
on
Euthanasia, 1980:
1) No one may permit the killing of
an innocent human being even
when "suffering from an incurable
disease, or a person who is dying."
Further, "no one is permitted to ask
for this act of killing, either for
himself or for another person
entrusted to his care."
2) When inevitable death is
imminent in spite of the means
used, it is permitted in conscience
to take the decision to refuse forms
of treatment that would only secure
■3?
a precarious and burdensome
prolongation of life, as long as the
/ normal care due to the sick person
in similar cases is not interrupted.
The examination of several
points in the last statement would
provide some clear guidelines for
the withholding of AHN.
1) AHN is a medical treatment.
However, as it supplements normal
nourishment essentially required
- F
for life, and is generally noninvasive
and benign, stronger reason is
Tc.needed for discontinuing it than for
many other medical treatments.
2) When death is imminent. This
does not merely mean that the
person would die without AHN. It
means that death will occur even
with AHN soon, say, within a
month. (Some would extend the
period longer).
3) Precarious and burdensome
pcolongation of life. One is obliged
Io continue with AHN even if it does
n°t
improve
patient's
the
condition. The idea is basically to
support
maintain
and
the
condition as much as possible. One
can end it only if it prolongs unduly

Z

Controversial!
Euthanasia, often called "mercy
killing", is a crime everywhere in
Western Europe. But more and
more doctors and nurses in Britain,
West Germany, Holland and
elsew'here
readily admit to
practicing it, most often in the
"passive ” form of withholding or
withdrawing treatment. The long
simmering euthanasia issue has
lately boiled over into a sometimes
fierce public debate, with both
sid&s claiming the mantle of
ultimate righteousness. Those
opposed to the practice see
upholding sacred
themselves
principles of respect for life, while
those in favour raise the banner of
humane treatment.
— News Week
■-

the process of dying and not of
livingwith a minimum of comfort. If
the treatment, together with the
attendant hospitalization, is too
burdensome in cost or in tolerating
the artificial procedure, there is no
more obligation to continue it. If the
feeding is futile e.g., if intestinal
disorder prevents absorption, it
need not be provided. Before
discontinuing the AHN, one must
ensure that the patient is
adequately prepared for death.
4) ‘Normal care is not interrupted'.
Feeding itself is normal care. When
it is artificial, it may be withheld in
certain
circumstances.
Other
'normal care’, i.e., keeping the
patient in reasonable comfort
should be attended to. The dying
patient is a human person who
calls for respect, care and concern.
5) Decision to refuse treatment.The
patient himself has no right to
refuse reasonable treatment, here
AHN. Hence one is not to accede to
HEALTH ACTION — JULY 1988

his wish if it implies suicide.
However, if an unwilling patient has
to be continually force-fed or has to
be completely rendered uncon
scious to provide AHN, it may be
The
discontinued.
protracted
physical or chemical restraint
would go against his human
dignity.
The decision to terminate AHN in
the case of an incompetent patie-*
is to be taken by the fam
However, the doctor cannot accede
to their request if it appears clearly
unreasonable or if the doctor
perceives that they are directly
intending the death of the patient. If
the patient is permanently or
irreversibly comatose, AHN need
not be provided. However, as such
judgements may prove wrong, great
prudence is needed. A competent
adult may refuse any treatment,
including AHN, which he clearly
finds to be excessively burdensome
or futile.
In continuing or withholding
treatment,
‘quality
of life’
judgements should not come in
since no human life is useless. Such
judgements would lead to grave
discrimination against the severelv
handicapped, in incurably sick <
so on. However, many authors
would permit discontinuance of
treatment when there is not even
minimum capacity to relate. This
seems to be verified in the case of
irreversible coma.

Starvation deaths
Some 15 million children die of
hunger annually, says a World Bank
report on the current food situation
in the world. Outlining hunger as the
most frequent cause of death, the
report says that dearly 40,000
children die of starvation daily.
Nearly one-third of the world’s
population fails to take in food with
sufficient caloric value.
- The Hindu

37

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MEDICAL ETHICS

Medical Ethics Forum
Fr. GEORGE LORO, S.J

f
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Reducing Incidence of Abortion
It is generally estimated that
there are as many as 50 million
abortions a year in the world, of
which about 6 to 7 million in India
alone. So more human lives are
destroyed in this way than in all the
many wars in the world. Most
abortions in India are performed by
quacks with a high risk of death or
serious injury to the woman. Even
abortions done in clinics have their
physical
own
and phychic
consequence. Besides, medical
personnel
increasingly
are
becoming ministers of death rather
than ministers of life by being
involved in what is being
euphemistically called Medical
Termination of Pregnancy (instead
of the proper name killing unborn
babies'). The large number of
abortions coarsens the moral
sentiment of the people and paves
the way for other forms of violation
ofhuman life. However, it must also
be admitted that these other forms
like brutal suppression of blacks in
South Africa, wars among poor
nations stirred up by the mighty
and various kinds of terrorist
activity in turn pave the way for
killing unborn human beings who
for some reason are considered
inconvenient.
To tackle such a mighty evil, it is
not enough merely to condemn
abortions. Its causes must be
analysed and remedied at the root.
Some of the points that need
particular attention are dealt with
here.
Value of Human Life
First of all, the unique value of
human life is to be fostered. Human
Hfe is specifically different from
animal life, which point does not
seem to be clear to many people.
Man, being made to the image of
God (Gen. 1:27), his life is most
precious. God alone has mastery
over human life; man has only a
stewardship. Although earthly life

is not the ultimate human value, it
is the most basic value upon which
all other values depend. Hence no
one has a right to take away the
right to life of an innocent human
person for any reason.
Fundamental Equality of All
Human Life
The current trends of democracy
and socialism, if they mean
anything at all, should support the
idea that all human life is basically
equal in value. The life of a human
person may never be suppressed
on the plea that it is undeveloped,
has less potential for human
existence and so on. Of course, in a
world where the lives of the poor
are suppressed for economic or
other selfish interests of the
dominant groups, it is natural to
think that the life of a small,
dependent or inconvenient foetus
may be terminated. So there is the
need for strongly defending the life
and dignity of every human person
regardless of race, caste, status or
economic ability. Those who wish
to condemn abortions must equally
condemn the oppression of blacks
in South Africa, of the Arabs in
Israeli occupied territories or of the
Harijans in India. Conversely those
social
who condemn other
oppressions should also condemn
the killing of unborn human beings.
There should be no selective
reaction which creates a wall of
misunderstanding between two
groups of people.
Equality of Boy and Girl
One of the evils that is fast
spreading in the country is
aminocentesis with a view to
determining the sex of the foetus
and aborting it if it is found to be
female. This is a strange and cruel
aberration. It is due to an ingrained
sense of discrimination and is
partly due to the evil institution of
dowry.
Christian
revelation
proclaims the total equality of male
female.
Whatever
the
and

differences between the sexes, the;
are meant to be complementar
not
excuse
fc
an
and
discrimination leading even tc
physical elimination.
Sex Education
A
number
of
unwantec
pregnancies arise [because of th
lack of knowledge and pmue
values regarding sex amon
h
youth. It is not only a question c
regarding
instruction
th
reproductive proce ss. There is evei
more need of inculcating thi
proper attitude to sex both on th'
part of the boy and the girl. Basil
instruction on mutual respect, th
psychosexual re flexes o f either se
and the way of coping with sexua
attraction and arousal are needed.
Effective Family Planning
Most abortions today can be
attributed to unplanned pregnan
cies
in
The
marriage.
socioeconomic situation today and
the drastic fall in infant mortality
calls for careful exercise of
responsible parenthood. For this
there is the need for effective
methods of avoiding conceptior
when a new pregnancy i1
tot
indicated. If we —
regard N<^rai
Family Planning as sufficiently
effective and as the best method
from the integrally human and
moral point of view, everything
must be done to make the approach
sufficiently known and understood
by all fertile couples. One-sided
condemnation of contraception
with half-hearted promotion of NFP
inevitably leads to large scale
homicide or killing of unborn
babies.
Counselling Services
When an unmarried girl gets
pregnant she needs understanding
and support. Society should
abandon the double standard of
morality whereby the fault of the
boy is lightly taken and all the
burden of guilt is placed on the girl.
Contd. on page 42

HEALTH ACTION — APRIL 1988

I

___ I
MEDICAL ETHICS

Dhy-

Medical Ethics Forum-50

and
low
ia. A
itest
laria
be
iurs

Ethical Implications of Reproductive Technologies
Fr. GEORGE LOBO, S.J.

A
aeve
s or
=rom

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toils
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able
the
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and
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aro3ful.
acai
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the
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ll

Medical Science and Ethics
“Good medicine is good morals”.
This holds good when medicine
respects the basic values and rights
of man. However, all that is
technically feasible is not ethically
justified. Medicine is meant to
safeguard human life and enhance
the quality of life. When it violates
these values, it fails its own
purpose. Although the advances in
modem science and technology in
the field of medicine are to be
welcomed as a gift of God and result
ofman’s dedication, their use is not
value free and hence ethically
neutral. Hence there is need of an
ethical control, especially in the
now rapidly expanding field of
medical science. While scientific
and applied research constitute a
significant expression of man’-s
dominion over creation, in fact, over
his own body and mind, these are
to be placed at the service of the
human person, of his inviolable
rights and his integral good.
Reproductive Technologies
We must be grateful that fertility
is no more a matter of blind fate. A
knowledge of its processes and the
ability to direct them has made it
possible to correct a number of
defects that would affect the
parents or child. But care must be
taken that their basic dignity and
values are not violated. No one by
virtue of his scientific or technical
competence can lay claim to decide
°n a person’s origin and destiny.
Evil of Abortion
Vatican II has condemned
abortion together with euthanasia
as an abominable evil’ (Church in
the World, N. 51). Physical life is not
jpan's ultimate or supreme good,
but it is his fundamental value
'vhich no one may violate under
a9-V pretext or for any reason. To
^stinguish between bom and

L
11 . _________

Ip
I

I
I

unborn life or between developed
and undeveloped life or between
male and female foetuses would
imply gross discrimnation between
human beings. Every human
person, whatever his state or
condition, has the same basic right
to life. Today’s consciousness of
social justice calls for the defence of
the weak,, dependent and helpless
people.
The
over 50,000,000
abortions a year in the world today
constitute one of the grossest
violations of human rights. Apart
from the colossal and wanton
destruction of human lives, they
cause untold damage to women
and coarsen the fabric of society.
The violation of human life on such
a vast scale is the result of
unchecked homicidal tendencies.
It in turn aggravates the prevailing
tendency to kill and destroy human
life at every provocation. Those who
are dedicated to the promotion of
social justice are called upon to
defend the right of the unborn to
their life. Reciprocally, those who
oppose abortion must be careful to
condemn the massive killing of
innocent
like
people
the
Vietnamese during their struggle
for national liberation.
Female Foeticide
Misogyny or man’s inhumanity
towards woman, had its most cruel
manifestation in the killing of
unwanted female neonates by
exposing or strangling. Now this evil
is staging a comeback. Not only is
there increasing bride - burning
under the appearance of suicides’
or ’bums’, but female neonates are
exposed to death by starvation or
are just killed in order to forestall
the crushing burden of paying
escalating dowries. Often the poor
mother herself is made to perform
the act.
HEALTH ACTION — MARCH 1988

r-

Of

late,

sex

determination

techniques like amniocentesis are
used to discover the sex of the
foetus and when this is found to be
female, abortion is resorted to.
Amniocentesis was first introdu
as a diagnostic procedure to detect
genetic abnormalities in the foetus
with a view to possible treatment.
Now, especially in India, it is being
largely used as a njieans of sex
determination leading to abortion
of unborn female babies. The
irrational bias towards male
progeny is exploited by commercial
minded diagnostic centres.
Apart from the killing of female
foetuses, the risks to the child and
the mother from the procedure
itself cannot be overlooked. The
risks may be minimized by some
more recent methods used for
prenatal
sex
determination.
However, amniocentesis is still the
favoured method in the country.
Moreover, there is a margin of error
leading to the abortion of foeh
s
.3
that turn out to be male.
resulting trauma for the family can
only be imagined.
Discrimination on the basis of sex
arises
primarily
from
the
destruction of female human lives.
Hence the fundamental issue in the
matter is that of the morality of
abortion.
The outcry in feminist circles
against selective destruction of
female foetuses would be more
justified if the evil of abortion in
itself is more clearly recognised.
Morality of Sex Selection
must
Men
realize
that
discrimination against women, not
only affects women, but is also
against the best interests of the men
themselves. Man can achieve
fulfilment only through respect and
partnership with woman. The
39

MEDICAL ETHICS

o

I

What is the basis for the
Churchs ’ Stand on
Family Planning ?
.

fulfilment of which is equally
According to the stand of the
necessary-for salvation.” (N. 4).
Church, married peoplemust
exercise responsible parenthood.
As to the methods for regulating
The encyclical points out that the
births, the . Church holds that
problem of birth regulation must be
artificial methods of contraception
considered 1) in the light of an
are evil and natural family planningintegral vision of man and of his
JBH vocation; 2) a sense of conjugal love
^s-*fsuch is advocated. These -points
♦«««traced
I t0 tocoHsidered
in its
origin,
cannott. be directly
considered
in supreme
its supreme
origin,
Scripture texts or injuctions.
QOCj vvho is love, "the Father from
However, they are derived from the where every family in heaven
I
insights of natural law which are on earth is named" (Eph 3:15); 3) u us
supported by the biblical vision of fov” is to be ftjily human, total,
man.
faithful and exclusive until death,
. and fecund; 4) conjugal love
The Bible teaches that human
requires an awareness of the
nature as made by God is good. As
mission of the. i spouses to
man is made to the image of God
'responsible parenthood ’ which
(Gen 1:27),his very nature manifests
implies a profound relationship to
the manner in which he should act,
the
moral
order
objective
not by blind instinct as animals do,
established by God, ofwhich a right
but
with
deliberation - and Conscience
the
is
faithful
responsibility. This so called
interpreter. '
L
natural law’, based on’the veiy
nature of man, provides a common
.
.........
standard of values for all people
The spouses are to conform their
and enables persons of different sexual activity to 2 the creative
religious persuasions and even '’intention of God, expressed in the.
non-believers to enter into common veiy nature of marriage and of its
discourse on vital --problems, facts, and manifested by constant
especially in the medical field.teaching of the Church. This
Today this is all the more necessary ?’ ; teaching insists on the inseparable
. c •; connection between the
)
in a pluralistic world. V
r . ./ meanings of the conjugal ^ct, me
The New Testament speaks of unitive
and procreative. - In
Gentiles who do not have the concrete, the Church’s Magisterium
.condemns artificial methods of Jewish law "doing by nature what
the law requires." "They show that
contraception as frustrating the
what the law requires is written in natural dynamism of the conjugal
their hearts. ” (Rom 2:14-15). Hence, act Towards procreation, while it
although the natural law and the
approves natural family planning as
i_.-_ are
xi distinct; they
implying
< such a disorder. .
Gospel teaching
:
..
are not to be separated. One is
based on the other. It is ; by '
Thus the teaching of the Church
recognizing and observing the
on family planning is based on the
natural law imprinted in the hearts
sanctity of human life and its
of all people that we have
.j - responsible transmission which
concretely to observe the'law of the
values are derived from the biblical
Gospel'. .
y.
vision of man. In practice, there are
The encyclical Humanae Vitae of often difficulties 4 in conflict
situations. While these have*to be
Pope Paul VI on Regulation of Birth
sympathetically understood, the
claims the competency of the
Church’s teaching authority to medical profession must strive to
•interpret even the natural moral make the practice of natural family
law "which is also an expression of planning feasible and so that such
difficulties are minimized.
the will of God, -the faithful
’
45

HEALTH ACTION — EEBKl'AKY 1‘JKM

(
•’5..

MEDICAL ETHICS FORUM

Concealing

the
Truth

Honourably
Fr George Lobo SJ

se: A good and devoted husband in
a moment of weakness is unfaithful
to his wife for only one time. Weeks
later, he realizes he has contracted
genhorrhea and presents himself to
his family physician for treatment.
He requests the physician to treat
his wife also who has an appointment
for a routine check up, without
revealing to her any diagnosis of
venereal disease should she have
contracted it. He fears for his
marriage and her feelings.
Normally, the patient has a right to
be clearly informed about his/her
condition. It is not right to proceed on
the assumption that truth does not
matter and the only concern of the
physician is to seek the physical
health or other interests of the
patient. On the other hand, this is not
absolute norm. It would be a
| simplistic position to say that the
, patient has the right to be informed
i even if it is very likely he will
! immediately jump out of a 4th story
I window. We should keep clear of the
, opposites of cynicism about the
; patient’s right to the truth and brutal
i revelation of the same. The patient
i has a real right to the truth, but it is
equally clear that the right has
■ definite limits.
Thus the physician is not bound to
! If you ever find happiness by hunting
for it, you will findit, as the old woman
did her lost spectacles, safe on her
own nose all the time.
Jose Billings
50 • HEALTH ACTION DECEMBER 1988

49

Weight gain which may be the
result of renewed appetite occurs in
some patients. Beware — do not use
it for this. Among the other Ride
effects seen are skin rash, nausea,
headache, impairment of sexuai
function, vertigo and lightheaded
ness.

Journal

Various jc
regularly at C
Association o
are of intere
dcoumented
conscious pec
any of the
please write
Department,
Agranulocytosis (severe depres Secunderaba
sion of the granulocytes) and hepatic 6D ps per pac
payable.
(liver) reactions have been reported
though rare. Menstrual irregularities I Health Car
have been noted and women may fail 1
Ten years ai
to ovulate while on the drug.
by John H B
World Heat
Overdosage with this drug is
give information that would 1) cause
August — S
frequent. It can cause respiratory
great harm to himself; 2) to the
depression especially so in children; 2 Politics of N
patient; or 3) to other persons.
Medical wor
large doses can be fatal.
In the present case, the physician
by Anant RE
If taken by a pregnant woman
is morally obliged to conceal the
Medico Frie>
July — Augu
there are chances that the fetus can
truth from the wife in order to
develop cleft lip or palate. It can 3 Politics of
protect the marital relationship, and
depress the functioning of the
Perpetuatec
to use human language effectively to
Sector
do so.
central nervous system in the new
by Sathyame
born especially premature ones.
A
mature wife would not
Medico Friei
While Diazepam is a useful drug
July — Augu
reasonably expect that a physician
when indicated, it becomes a health 4 Issues for de
would give her information which 1) is
hazard when taken for little or no
Health Care
not strictly necessary to treat a
by C R Bijoy
reason. Most often one needs to
mysterious vaginal infection; 2)
Medico Friei
_. ___
handle life's situations and sort out
would inflict useless mental anguish
July — Augu
on her;
I
.............................../
3)
would needlessly humiliate
problems that may be the cause of
tension, anxiety and sleepless nights. 5 Skin drug ca>
a repentant husband; and 4) would
The Hindu
severely strain the marriage.
Should I further elaborate on the
October 16
many other fashionable 'Home 6 Predicting
Suppose the wife were to ask:
remedies' lying on your shelf?
You don't believe I have a venereal
Birthweight
better?
Definitely it will continue with this
disease, do you?” to say "I will not
. Journal of Tr
tell you" would be quite ineffective in
same warning note 'Beware of the
February 19
drugs
you
so
readily
take,
whether
it
concealing the secret. The only way
7
Polio
Vaccine
be an Aspirin, Baralgan, Septran,
the physician can proceed is to
by Vishwas F
calmpose or even Vicks!
answer in words which have two
Health for tf.
meanings: one a somewhat more
August 198f
Just keep this in mind before you
obvious meaning (which the wife will
pop in your pill —
8 Polio still Sts
very likely take) and the other a less
by G Ravindr
— Do I really need this foreign body
Herald of He
obvious but real refusal to answer. It
(drug) in my system?
November 11
is for the prudent physician to "
— If I do — why ?
9 Acute Diarrh
discover such a way of speaking. If
— How much do I know about the
Journal of Tr
the painful truth still comes out, it is
February 191
drug I am swallowing or letting
his duty to mitigate the shock of the
another
person
swallow?
10
Appendicitis
revelation.
|
by William D.
— If you do not need it, or know a
Herald of He
thing about this foreign body —
Winter is the season when we try to
November 15
don't take it, you will soon realise
keep the house as hot as it was in the
for
you can do better without it. 11 Strategy
summer, when we complained about
encephalitis
Believe me, I personally do better
the heat.
ICMRBulleti
without any of these drugs!
E2
August 198E

L

medical

ethics

forum

X Genetic Counselling
I

■r II
F-

I

I
.. T'
L

Fr George Lobo SJ

New Developments
The interest in genetic disease has
noticeably increased in recent years,
mainly because we are witnessing a
remarkable advance in the under
standing of genetic defects and the
ways in which they are transmitted,
This is causing an acute desire on the
part of many parents to know
whether they are carriers of genetic
disease or whether their children
already conceived are affected by it.
Hence a whole discipline of genetic
counselling is developing.

Genetic Defect
A genetic defect, in general, is a
disorder that results directly or indi
rectly from the information con
tained in the genetic material in the
human cells.
The congenital malformations may
be due to (11 single abnormal or
mutant gene; (2) chromosomal dis
order with abnormal number or
structure of genes; (3) multifactorial
in which both genetic and environ
mental factors play a role; (4) terato
genic, due to the effect of hormones,
radiation or other harmful agents on
the developing fetus.
Screening
Genetic screening programmes
aim at (11 detecting affected persons
to avert the consequences of the
disease; (21 detecting the carriers of
defective genes to provide reproduc
tive advice; and (3) identifying
affected fetuses.
Reproductive Advice
The counsellor places before the
concerned parents the chances of
their offspring suffering from particular genetic disorders. It is for the
Parents to decide whether to avoid
Pregnancy or take a risk according to
their desire of having a child and abil
ity to cope with a defective offspring,
'fie means of avoiding a pregnancy
should be morally acceptable.
At times, it is advisable to have the
sating done before marriage.

Prenatal Diagnosis
~ various prenatal
.C1iabai uia
diaqThere are
nostic techniques to detect qenetic
'
defects in the fetus.
The most com
. — x-: _

x

i

mon one now is amniocentesis which
has a high risk .factor unless it is
combined1 with ultra sono'qraohv'
The problem of justifying
the risk
y
arises since (al
cannot
— the
.—cannot
— fetus
consent to this experimental procedure and (b) usually there is no direct
benefit to the child.
Benefits of Amniocentesis
The following advantages may be
found.
1 The development of a fetus of a
diabetic mother can be monitored
in order to deliver it before too
much damage can occur. Similarly,
in
in thp
the r.PPP
case nf
of Oh
Rh inrnmnot-ihillf-w
incompatibility
other treatment could be used.
2 Some genetic conditions like phenylketoneuria (PKU) could be
treated by modifying the diet of
the child from birth.
3 Advanced warning could allow
physicians and parents to prepare
to deal with the child. There may

be time to work through the nega-

tive feelings. However, it may also
have the opposite effect of
increasing rejection feelings.
4 The negative results may assure
the mother who otherwise may go
in for indiscriminate abortion or be
so anxious that it would affect the
child adversely.
Abortion Never Licit
Unfortunately, the diagnosis is
often made with a view to abortion of
a defective child. The diagnosis then
becomes the equivalent of a death
sentence. This is evidently never jus
tified. However, the counsellor and
others must support the family and
provide other realistic alternatives.
Society has to come to the aid of a
family that has to cope with a
severely handicapped child.

Attitude of Counsellor
The genetic counsellor is to adopt
a non-directive attitude. However he
cannot but manifest his moral con
victions. The conscientious counsel- ;
lor would be expected to make it
clear that abortion is a grave evil and
is accompanied by many adv^ a
consequences. On the other f. j,
with goodwill and effort, it is often
possible to raise defective children to
a reasonable degree of good life.

I
Sex Determination
The increasing problem of' deter- j
mining
”"”2 the sex of the fetus through
amniocentesis with a view to abort- I
ing the^female fetus is most .pernicious. Besides the killing of "unborn
’ it
‘ has the (malice of a
"r life,
human
grave discrimination Againstj the
fpmnlp
female cpv
sex. NA/Hrir-.
When don^ __
on__a large
scale, it will seriously disturb the
.2 sex
ratio in the population with grave
attendent consequence^,,

Announcement
Efforts are being made by the
private sector to promote ration
dru^ therapy. Ratnagiri Drugs A
Limited and Comprehensive
Medical Services - India (GMS-I)
are making available essential
drugs by their generic name and
these will be made available at
reasonable rates.
For details contact
Dr Wishwas Rane
Marketing Director
Ratnagiri Drugs Pvt Ltd.
142 A Krishnakunj
Shivaji Park Road
Mahim Bombay-400 016
KV Joseph
Sr Project Executive
Comprehensive Medical
Services-India
93, Pantheon Road, Egmore,
Madras-600 008
HEALTH ACTION NOVEMBER 1988 • 43

MEDICAL ETHICS FORUM-47
By Fr. George Lobe, S.J.

Sterilizing the Severely Retarded Woman

$

I
i

Case: A severely retarded woman is in
constant danger of sexual seduction and
sexual assault from several men. Periodi
cally she gets pregnant and her guardians
have her undergo abortion. Would it be
licit to have her sterilized to protect her
from criminal impregnation and the need
for abortion?
It is obvious that under no circumstance,
abortion or the killing of unborn human
persons would be licit. It is also clear that
any possible ‘defensive sterilization’ could
be thought of only as a last resort. Other
wise, we would not be far from the excesses
of Nazi sterilization programmes in Ger
many when thousands of women were
are retarded or
sterilized because they
because they might bear defective offspring.
The first line of defence should be
education in self-management. The potential
of retarded persons to develop their basic
self-respect and power of assertiveness
cannot be minimized. Every effort then
should be made to bring them to a mini
mum of self-awareness and self governance.

(
!
<
I

If this is not possible, the second line
of defence should be adequate custodial
care. The guardians, failing which, society
has the responsibility of guarding retarded
women from sexual degradation. There is
need for strong legal sanctions against
seduction of mentally handicapped persons.
The public should also support centres where
such people can be sheltered and taken
care of.

June 1987

However, what of extreme cases in
which the above two-lines of defence are
not available? Here the principle of defen
sive contraception may be allowed. For a
long time now, even conservative moralists
have been admitting the permissibility of
from forced
impregnation.
protection
According to them, illicit contraception is
''deliberate sexual action and the deliberate
blocking of its procreative effect.”

In the 1975 document of the Congre
gation for the Doctrine of the Faith regard
ing “Sterilization in Catholic Hospitals”,
any direct sterilization is declared illicit,
since “it deprives subsequent freely chosen
sexual acts of an essential element. ” (Acta
1976, pp. 738-40).
Apostolicae Sedis,
purpose in which
contraceptive
Again
Catholic hospitals are not to cooperate is
defined as “the impeding of the natural
effects of the deliberate sexual acts of the
person sterilized.”
Hence it seems that in extreme cases,
the protection of a retarded woman from
unjust impregnation through sterilization
would be' justified. As the person is not
personally competent, the consent of the
rightful guardians would have to be obtain
ed.
Admittedly, this is an extreme solution
to an extreme case.
It is always to be
hoped that the problem could be handled
through a less drastic way.
23

J

Medical Ethics Forum
—by Fr. George Lobo, S.J.

Refusing to Eat

■I

r

G

I
3

Case : K young woman badly handi
capped by multiple sceloris refused all
zfood. She was able to chew and swallow
with relative ease; but the deteriorated
condition of her hands necessitated others'
feeding her. Was her refusal of food
justified by steadily increasing depen
dency on others for this and other basic
needs, the apparently hopeless
prog
nosis of her condition and her feeling that
life was for her generally lacking in ful
filment? Would the hospital have been
justified in force-feeding her?.
Everyone has the obligation of using ordi
nary means of preserving life. Simple nou
rishment is the most basic of all such means.
Those who believe that human life is a gift of
God would more readily agree that there is an
obligation to eat in order to live.
It is true that a patient may not be bound to
take food in vain. Thus a patient who has
only a few short hours to live need not take
food. A patient who cannot retain any food
need not go through a mere ritual of eating
if there is no hope that the purpose of eating
will not be at all achieved.
However, where normal intake of food is

possible for a given person and will signi
ficantly prolong life, be it ever so diminished
or ever so emotionally unsatisfactory, then the
patient has no normal right to refuse food.
It would amount to suicide, although by
omission.
Society may find it impossible to snatch
from the hand of every would be suicide the
poison with which he would want to end his
life, or to force-feed every despondent patient
who seeks to starve himself, it has the right
and duty to do, even using force if necessary
as a last resort.
The case is significantly different when
artificial feeding is used as a substitute for
normal eating which is physically no longer
possible for a particular person. The stroke
victim who can no longer swallow may not be
morally obliged to submit to a frame of arti
ficial feeding which he or she finds extremely
painful. A case can be made also for with
holding or withdrawing artificial feeding from
irreversibly comatose patients. In such a
case when the power connatural to the human
body for the intaking of food has been lost
and the patient or those responsible for him
or her may well judge that the expense of
physical discomfort is out of all proportion to
the benefits in continuing the procedure.

■I

I

32
I

I Medical Service

^iiwfe.

Medical
Ethics
1 A patient has the right to
Medical Ethics Forum
considerate and respectful care.
2 The patient has the right to obtain
from his physician complete current
information concerning his diagno
sis, treatment, and prognosis in
terms the patient can be reasonably
expected to understand.
When it is not medically
advisable to give such information
to the patient, the information
(Approved by Amercian Hospital
should be made available to an
Association, 1973)
appropriate person in his behalf. He
has the right to know, by name, the
physician responsible for coordinat
Fr George Lobo SJ t
ing his care.
records pertaining to his case should 10 The patient has the right to expect
3 The patient has the right to receive
from the physician information
be treated as confidential.
reasonable continuity of care. He
necessary to give informed consent 7 The patient has the right to expect
has the right to know in advance
prior to the start of any procedure
what appointment times and
that within its capacity a hospital
and/or treatment. Except in
physicians are available and
must make reasonable response to
emergencies, such information for
where. The patient has the right to
the request of the patient for
informed consent should include
expect that the hospital will
services. The hospital must provide
but not necessarily be limited to the
provide a mechanism whereby he
evaluation, service, and/or referral
specific procedure and/or treat
is informed by his physician or a
as indicated by the urgency of the
ment, the medically significant risks
delegate of the physician of the
case.
involved, and the probable duration
patient’s continuing health .care
When medically permissible, a
of incapacitation.
requirements following discharge.
patient may be transferred to
Where medically significant
11
The
patient has the right to
another facility only after he has
alternatives for care and treatment
examine
and receive an explana
received complete information and
exist, or when the patient requests
bill regardless of the
tion
of
his
explanation concerning the needs
information concerning medical
of
payment.
source
for and alternatives to such a
alternatives, the patient has the right
transfer. The institution to which 12 The patient has the right to know
to such information. The patient
the patient is to be transferred must
what hospital rules and regula
has also the right to know the name
first have accepted the patient for
tions apply to his conduct as a
of the person responsible for the
transfer.
patient.
procedures or treatment.
8 The patient has the right to obtain
No catalogue of rights can
4 The patient has the right to refuse
information as to any relationship
treatment to the extent permitted by
of his hospital to o^her health care guarantee for the patient the kind of
law and to be informed of the
and educational institutions insofar treatment he has the right to expect. A
medical consequences of his action.
as his care is concerned. The patient hospital has many functions to
has the right to obtain information perform, including the prevention and
5 The patient has the right to every
as to the existence of any treatment of disease, the education of
consideration of his privacy
professional relationships among both health professional and patients,
concerning his own medical care
individuals, by name who are and the conduct of clinical research.
program..Case discussion, consulta
All these activities must be
treating him.
tion, examination and treatment are
confidential and should be 9 The patient has the right to be conducted with an overriding concern
conducted discretely. Those not
advised if the hospital proposes to for the patient, and above all, the
directly involved in his case must
engage in or perform human recognition of his dignity as a human
have the permission of the patient to
experimentation affecting his care being. Success in achieving this
be present.
or treatment. The patient has the recognition assures success in the
6 The patient has the right to expect
rig^ht to refuse to participate in such defense of the rights of the patient.
research or projects.
that all communications and

A Patient’s Bill of
Rights

Health Action December 1990 • 19

»

Medical
Ethics
Forum

____________

ing activity”, facilitating questions,”
“deepening reflections” and, if possible
catchy songs; the community anima
tors and present to them. They in trun
go to their respective communities and
act out the message. And lo, the entire
village will be ringing with the theme.
This we have done not at the level of
just one village, but simultaneously in
clusters of villages.
Our plan is gradually to get these
health ministers organized into
promotional, decision-making and
interacting structures at village, zonal
and district levels.
As Hundreds of thousands of such
mmunities are already functioning
in the various countries of Latin
America and else where, it is again not
presumptions to think of even a global
network of such structures.
What do we intend to do through
all these structures and program
mes ?
Well, our overall approach will be
as follows:
—using the above mentioned basic
communities as fora for non-formal
education, discussions, and decision
making for health action at
grassroot level.
—organizing representatives of these
communities for decision-making
at village, zonal and district levels.
-gradually experimenting a health
insurance process, with tie-up
arrangements with referral hospi
tals, in such a way that people can
get health care at rates far cheaper
than what they are spending now.
(Recently we had a survey taken in
a coastal village. People have been
spending nearly four thousand
rupees on an average per family per
year for hospital and medical
expenses.
—Ensuring the above process, not
only by resorting to alternate, and
self-help therapy systems as much
as possible, but also by insisting on
preventive and promotive aspects
of health care.
34 • Health Action October 1990

Medical Ethics Forum

Medical Ethics Education
Fr. George Lobo S.J.

Training of physicians and other
health professionals has generally
included some form of instruction in
medical ethical norms down the ages,
The ancient Hindu oath found in the
Caraka Sambita was phrased in terms
of the precepts in which a teacher
should instruct his disciple. The Greek
Hippocratic Oath functioned as a basis
of the instruction of the young
physician in the Western world.
However, little formal education in
medical ethics remains in most present
day medical colleges. The Indian
Medical Ethics Code is dealt with from
a legal point of view to forestall legal
liabilities. Some discussion takes place
in various magazines on topics like
euthanasia and compulsory sterilization. At times we hear reports of
certain malpractices by hospitals or
individual physicians. This is often
well-intentioned, but from the nature
of the case sporadic.
A host of questions like abortion,
euthanasia, family planning and organ
transplantation as well as decision
making regarding special forms of
treatment or the use of life supporting
systems call for ethical evaluation,
Otherwise, the patients will become
objects of technological manipulation,
and not persons whose dignity and
rights are to be respected.
And when we speak about
promotive aspects we mean not only
social justice and political dimension
of health action and the interrelatedness of health and development, but
also the all important aspect of
participation.
Participation is health:
We would almost believe that a
non-participant person is a sick person,

Hence it is quite clear that formal
teaching of medical ethics must be
given sufficient importance in medical
and nursing schools. The coutse must
be well organised and competently
handled, although several methods
could be adopted in conducting it. A
combination of lectures on ethical
principles, discussion of concrete cases
and seminars on special themes would
be the ideal. The course should be
closely linked with various i medical
disciplines.
The general public must be initiated
in ethical reflection especially
regarding questions like abortion and
euthanasia. Unless there is sufficient
advance thinking, people would be
deceived in matters like sale of organs
for transplantation. The informed
consent, legally or morally required for
special procedures like surgery would
have no meaning unless there is a
minimum of capacity for ethical
judgement.
Some training in medical ethics is
also required for all those who are in
the caring professions like counsellors
and clergy. They may misdirect their
clients if they do not have sufficient
grasp of the ethical implications of
many medical procedures.

And our structures and actions, if they
don’t achieve anything else other than
just allowing people little more
participationand thus little more sense
of human dignity as equal partners in
the enterprise of life and world, we
presume, we would have contributed
quite a lot to building a healthy world.
Some presumptions are worth
having, isn’t it?

I

I

I

Medical
Ethics

Humanized
Health Care

egalitarianism in practitioner-patient
relationship. Patient vulnerability and
dependency can strengthen this latent
power of professionals. But the
inherent dignity and rights of the
patients must always be respected.
Fr George Lobo, S.J.
1 Health care consumer movements,
I which are just beginning in India, can
1nn
the nnti'anil’r'
Medical Ethics Forum]I help in
in defending
patient’s rights.
-Awareness of the factors of
! But this should not overly jebpardise
depersonalization and dehumaniza
I the rights and interests of health care
tion, (see previous chapter), should
workers.
help in counteracting them. Here the
Emotional Factors
topic is dealt with in a more positive
Practitioners must feel and express
way.
empathy and warmth towards their
Three images of the human person Social Structure of Interaction
patients. But this demand is not
The patients 1) must be recognized without its difficulties.
; essential for a humanized health
care relationship. Patients must be as autonomus persons; 2) They must
If health workers over identify with
viewed as 1) unique; 2) irreplaceable share in decisions affecting their care; the patients, they might totally expend
whole persons; and 3) as inherently 3) Their relations with caretakers must their emotional energy and be illworthy of concern.
be e^ua/and reciprocal, not inferior or equipped to handle demands of
1) The condition of patient submissive.
efficient medical practice. Affective
1) The debility of the sick person involvement can threaten objective
uniqueness may look contrary to the
universalistic ethic calling for impartial must not cause ignoring his or her decision making and the authority
care: “a patient is a patient” But the basic freedom. Rather, the loss of needed to assure therapeutic comp
two axioms are not contradictory. The freedom which sickness often entails, liance.
universalistic ethic says that all patients must be attended to. It is true that
However, the suggestiqn that
equally deserve to be defined as unlimited freedom of the patient may practitioners should be affectively
patients; whereas the ethic of infringe on the freedom of others, neutral in their feelings and actions
uniqueness says that each deserves to including caretakers. But the humaniz- may depersonalize the providers as
be treated as an individual with unique ing and curative effects of autonomy well as the patients. Hence a delicate
qualities, needs and desires.
must be recognized.
balance has to be struck in order to
2) Within the limits imposed by arrive at a genuine but restrained
2) Health care workers may be
forced by limited skills or resources to physical and situational constraints, emotional commitment to patients.
tow their focus of concern. Indeed, patients must be autonomous with
uome point, their responsibility ends, significant control over their destinies,
and that of the family and society The right to give “informed consent ”,
begins. Moreover, a patient’s rights whenever possible for various
have to be recognized and a too treatments and procedures must be
WANTED
comprehensive health care may respected. All forms of manipulation
Nurse, Anaesthetist:
become invasive and infringe on these should be avoided.
rights. Still, the health care workers
with or without experience,
However, It should be noted that
must not lose sight of the total person sick people cannot always absorb all
Apply with all the details
and the need for a holistic approach.
the information necessary for a
including expected salary
3) The inherent worth of every rational decision. Fear and anxiety
Apply to:
person, whatever his or her state, even may affect their power of decision.
if it has reached the limits of Hence they should be spared the type
degradation, must always be kept in of information they cannot face. At
The Administrator
mind. The image of God may be times, decisions may have to be made
ST. LUKE’S HOSPITAL
dimmed in some states, but it never by guardians, and in emergency
Shrirampur-413 709
disappears. Rather, it is for health situations, by the health caretakers.
Dist. Ahmednagar (M.S.)
workers to recognize it and enhance it
3) The expertise of prof
,r:
as much as possible.
may seem to come in th'

n

T------

38 • Health Action September 1990

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■ 1
Medical

Depersonalization is the splitting of

Dehumanization
of Health Care

the psychological and physical self:
and dehumanization is the feeling that
one is isolated from others and
regarded as a thing rather than a
person. The terms have a wide variety
of ethical connotations which are
Fr George Lobo SJ
usually implicit rather than explicit.
The concepts refer to 1) the process of
objectification in human perception;
!
Medical
.7
2) to man’s exploitation of fellowmen;
3) to indifference and coldness in
Ethics Forum
human interaction; 4) to constriction
of human freedom.
1) Objectification here means that
rcople are being perceived and treated
_ - ---*
as things, as unfeeling quantitative
status, mental illness. institution tend to resemble those of
objects with standardized parts and as sex, social
underserving of other institutions.
considered
same
is true of
whde“s. Thus people are being viewed Th^' are c .
ing the
appropriate
concernThe
of care
to
standard of
care to
as njacb-nes and parts of a systenr the
^tandard
stutus persons
Patients may be forced to interact with stutus
pci suns are entitled, and
—
priorities and distribution of goods and services. The
accordingly
lower
hardware instead of human providers
following processes are at work:
and may themselves be seen as reduced resources are allocated to beaurocratization of services, seculari
extensions of tubes, respirators and them.
3) “Depersonalization” generally zation of values, over professionaliza
monitors.
tion of skills and proliferation of
Objectification also occurs when implies an absence of warmth in technologies.
patients are perceived as pathologies. human relations. A certain amount of
In the name of efficacy, the process
As a result of specialization, health emotional distance is functional for all of care is standardized, individuals are
workers may tend to stereotype professionals. But it may be perceived converted into impersonal figures, and
patients as organs or diseases (“gall by the patients as cold indifference.
4) At the core of dehumanization is anonymous channels of communica
bladders” or “hypertensions”) rather
tion are developed.
than as whole persons. The providers powerlessness and loss of autonomy.
A number of dehumnizing ideolotheir own
own Individuals are not masters of their
will be focussing on their
gies
curbed,
coopted
and
permeate helath care systems and
iorities rather than their patient ’s destiny, but are <
priorities
often
internalized by the victims
are
manipulated, into conformity. Thus,
perspectives and needs.
patients may be too restricted in their themselves. These include the
2) When “dehumanization” refers movements and compelled to receive following beliefs: that health‘i care is a
to exploitation in medical setting, it
right, that
visits under
under circumstances that privilege rather than a i\
signifies that people are being used visits
preclude privacy. Especially in long- certain illnesses are morally reprehensiinstrumentally without regard for the
»i«.’ «*
mom .
pain and suffering, as guinea pigs are ato’^^rien^Zatfonor
- - x,--x
1-------- 3 are omni
•isolation
abandonthat -physicians
used. The prototype is the experimen
potent, that the role of health workers
tation in Nazi concentration camps. ment.
’ ’ J care is
When caretakers are undertrained, to provide tender loving
Now subjects may be coerced into
with their
\...
correlated
inversely
participation and 1without being overworked or drained of emotion, technical competence.
adequately informed of the nature of these elements of depersonalization
This trend towards depersonaliza
ofr patients tend
the experiment, the risks involved or and dehumanization
1
and dehumanization needs to be
tion
to be aggravated.
alternate treatments available.
reversed.
One incentive towards this
It should also be noticed that
A more subtle mode of exploitation
be
would
the realization that
occurs when patients or even health dehumanization in health care is humanistic approaches to health care
workers themselves are degraded as linked to dehumanization in the wider are actually less costly and more
nonpersons or lesserpersons. They are society. The goals, values and
branded by certain characteristics such authority structures of the health care effective.

3

48 • Health Action August 1990

I

7

I

Medical
Ethics

c

■•■J-

The Oath, Alexandrian in origin and

dating back to about the fourth
century B.C., proclaims a stricter
standard of morality than was
contained in Greek law, Platonic or
Aristotelian ethics or common Greek
medical practice.

Reflections on the Oath
of Hippocrates

1) The opening clause pledges the
novice physician to become an By Fr George Lobo S J
adopted member of his teacher’s
family, to support his teacher, and to
pass on his instruction to the family
members free of charge. Such familial
bonds implied careful selection to the
heal profession.
. z) With remarkable insight, the
Medical
physician is asked to “apply dietetic
measures for the benefit of the sick
Ethics Forum
according to - my ability and
judgement.” Thus it foresees the
importance of proper nutrition in
health care.
:
3) The physician swears to keep the
' z'
patient “free from harm and injustice”,
implying preventive care and social
The Oath ends with a solemn
medicine. There is also a hint that the but is to be performed by those who
adjuration
asking for fortune for
patient is not to be financially are competent in it.
and
keeping
it
curse for violating it.
exploited. It also seems that the
For centuries following its appea
q
physician was required to minister to
6) iInn visiting the homes of patients,
the sick regardless of their social status. the physician pledges to “remain free rance, the Oath seemed to have had
impact on the medical profession.
4) “Similarly, I will not give to a from all intentional injustice, of all little
—
■
— • • •
’la
rise
and
sexual
The
of- Christianity
produced
mischief
in
particular
of
woman an abortive remedy.” This is
n^rticulalry noteworthy in a civiliza- relations with both female and male new idealism that gave meaning and
. in which abortion and infanticide persons, be they free or slave”. The substance to its provisions. Certain
physician is not to take advantage of modifications seemed to have been
were all too common.
- “In purity and holiness, I will guard his professional visit to cause any effected to bring it in greater harmony
my life and my art” Medical practice injustice or harm to the inmates of the with Christian values.
Medieval versions will replace
is to be regulated by an upright life and patient s house. The text displays a
sense of equality between female and references > to Greek deities by
honest dealings.
invocations more in harmony with the
5) “I will not use the knife.” This is rnale, free and slave,
monotheistic faith. In the spirit of
an excessive restriction that would
\ rule out surgery..
7) “What I see or hear in the course Christian brotherhood, the pledge to
seem to completely
Perhaps it is to be explained by the of the treatment or even outside of the teach the art of medicine is exteneded
crude surgical procedures then current treatment in regard to the life of men, to all who want to learn it, and without
which almost looked like butchery, which on no account one must spread any stipulation.
There was a significant revision of
However, the clause goes on to state: abroad, I will keep to myself.” This is a
“But I will withdraw in favour of such strong statement regarding the the Oath
. . by- the
. World Medical
confidentiality.
by
its Declaration of
of
Some
Association
requirement
men as are engaged in this work.” So
discretion
provided
by
the
1948.
However,
is
qualifying
Geneva
in
the original
not
but
is
surgery
banned,
is to be
performed by people assigned to it. clause; “which on no account one Oath continues to inspire the medical
Now surgery has become a refined art, must spread abroad. ”
profession in a large part of the world.
■ -r'

44 • Health Action July 1990

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Medical
Ethics
Forum

Organ Transplants from
Anencephalic Infants

3

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Medical Ethics Forum

Fr. George Lobo, S.J.
:■

i

1

Organ transplant experiments in the
United States and in Europe using
anencephalic newborns (babies lack
ing brain development) as donors have
raised the issue of the ethical
implications of such procedures.
It is now almost unanimously
accepted that whole brain death or the
complete and irreversible cessation of
all brain functioning is a well founded
norm for recognising the end of human
personal life. It would follow that
complete absence of brain function
would justify the conclusion that there
is no human personal life.
However, the difficulty is to
accurately define when whole brain
death or complete absence of brain
function is verified. Anencephalics
have no higher brain (cerebral
hemispheres), but in most cases do
have an existing brain stem. This can
sustain and regulate basic physiologi
cal functions including spontaneous
respiration.
To designate human personality
solely by the existence of what is called
the higher brain function would be to
admit a dichotomy between the
rational and other functions in the
human being. It would be to yield to
Cartesian dualism. Man does not think
only by his cerebrum or higher brain.
The thought process is an integrated
whole in which the whole brain in
some way participates. Hence,
although reason is the most specific
function of the human person, the
absence or death of the human person
cannot be accepted when the
brainstem is still functioning.
Therefore, it would be unethical to

transplant organs from anencephalic
infants. It would amount to killing
what atleast are probably human
beings.
It is more accurate to describe the
anencephalic as a human being and a

__ , ’__
3 who is severely would be killing one to save another
person,
but one
disabled. It is a case of an infant who is and hence ethically unacceptable.
truly born dying and the care that we
tAt present there are no applicable
are to provide any other dying guidelines to accurately declare brain
member ofour community ought to be death at such an early
t ’ age. There is no
given to an anencephalic.
point in putting an anencephalic infant
It should be noted that describing on life-support since it would not in
” : as nonpersons because any way benefit. The only way is to
anencephalic
they lack the capacity for relationships simply give the infant appropriate
would have serious implications for■ nursing care. When respiratory and
states of cardiac functions cease completely,
other people in various f.----disability. The desire of parents of al death may be presumed. Then the
live anencephalic baby to salvage organs may be taken out if they are not
some good from a tragic situation by damaged as the result of the dying
donating his organs to another child process.
STATEMENT OF OWNERSHIP
FORM IV (See Rule 8)

1

Place of Publication

: SECUNDERABAD

o

Periodicity of its Publication

:

3

Printer’s Name

: Ms Patricia Palaparti
at Pragati Art Printers
Red Hills, Hyderabad

(Whether citizen of India)
(if foreign, state the country of origin)

: Yes

4

Monthly (12 issues per year)

Address

Health Accessories for All
(HAFA)
Post Box 2153
Secunderabad-500 003 A.P.

Publisher’s Name
(Whether citizen of India)
(if foreign, state the country of origin)

Ms Patricia Palaparti
Yes

Address

5

Editor’s Name
(Whether citizen of India)
(if foreign, state the country
of origin)

6

Names and addresses of individuals
who own the Newspaper and

partners or share holders
holding more than one percent
of the total capital

:

Health Accessories for All
(HAFA)
Gunrock Enclave
Post Box 2153
Secunderabad-500 003 A.P.
Dr CM Francis
Yes

Health Accessories for All
(HAFA)

Gunrock Enclave
Post Box 2153
Secunderabad-500 003 A.P. y/

I, Ms. Patricia Palaparti hereby declare that the particulars given above are true to the best o^my
knowledge and belief.
Dated: 1.3.1990

Signature ?f~ the Publisher
Health Action

March 1990 • 21

Medical
Ethics
Forum

-

Medical Ethics Forum

INTERNkW NAL CODE ■
OF MEDICAL ETHICS

(a) Self advertising by physi
cians, unless permitted by the laws
of the country and the Code of
Ethics of the National Medical
Association.
(b) Paying or receiving any fee
or any other consideration solely
to procure the referral of a patient
or for prescribing or referring a
patient to any source.
A Physician Shall respect the
rights of colleagues, and of other
professionals, and shall safeguard
patient confidences.
A PHYSICIAN SHALL act
only in the patient’s interest when
providing medical care which
might have the effect of weaken
ing the physical and mental condi
A PHYSICIAN SHALL not tion of the patient.
permit motives of profit to influ
A PHYSICIAN SHALL use
ence the free and independent great caution in divulging discov
exercise of professional judge- . eries or new techniques or treat
ment on behalf of patients.
ment through non-professional
a PHYSICIAN SHALL, in all
channels.
types of medical practice, be dediA PHYSICIAN SHALL cer
cated to providing competent tify only that which he has per
medical service in full technical sonally verified.
and moral independence, with
Duties of Physicians to the Sick
compassion andI respect for
A PHYSICIAN SHALL al
human dignity.
ways
bear in mind the obligation
A PHYSICIAN SHALL deal
of
preserving
human life.
honestly with patients and col
A PHYSICIAN SHALL owe
leagues, and strive to expose those
physicians deficient in character his patients complete loyalty and
or competence, or who engage in all the resources of his science,
fraud or deception. The following Whenever an examination or
practices are deemed to be unethi treatment is beyond the physi
cian’s capacity he should summon
cal conduct:
■

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• •

Drawing on the Declaration of
Geneva, the WMA formulated a
more detailed code of ethics
which was approved by the Third
Assembly of the WMA meeting
in London in 1949. The International Code of Medical Ethics was
subsequently amended in 1968 by
the 22nd Assembly in Sydney and
again in 1983 by the 35th Assemibly of the WMA (World
:................
” 1
Medical
Association) at Venice. The text,
as amended, reads as follow:
International Code of Medical
Ethics
Duties of Physicians in General
A PHYSICIAN SHALL al
ways maintain the highest stand
ards of professional conduct.
36 • Health Action January 1990

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medical ethics forum-20

ee

FR. GEORGE V. LOBO S.J.

'el
he

Informed Consent

•n.
5S.

'er
ty
2d
)n
id
i-

is

al

d
s

1

3

Q.N.3 of the Patient's Bill of Rights (of.
Medical Ethics Forum-19) states that "the
patient has the right to receive from his
physician information necessary to give
informed consent prior to the start of any
procedure and/or treatment." What is the
scope of this information?
The required information cannot amount to
full disclosure". It would be unrealistic
to expect physicians to discuss with their
patients every risk of the proposed treatment,
no matter how small or remote. Some would
measure the required disclosure by "good
medical practice". Others by what a
reasonable practitioner would have dared
under the circumstances. Such a standard
based merely on a so called professional
standard would go against the patient's
prerogative to decide on projected therapy,
himself.
The patient's right of self-decision should
shape the boundaries of the duty to reveal,
i hat right can be effectively exercised only
• f the patient possesses enough information
to enable an intelligent choice.
The content of the disclosure rests in the
first instance with the physician. Ordinarily,
it is only he who is in position to identify
particular dangers. But on the basis of his
experience and the knowledge of his
patient's background and current condition,
he should be able to sense to what extent
revelation to the patient would be helpful
for the purpose of giving informed consent.
The materiality could be defined in the
following way. "A risk is material when a
reasonable person, in what the physician
knows or should know to be the patient's

j

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condition, would be likely to attach
significance to the risk or cluster of risks in
deciding whether or not to forgo the
proposed therapy."
The areas demanding a communication of
information are the inherent and likely
hazards of the proposed treatment, the
alternatives to that treatment, if any, and
the results likely if the patient remains
untreated. The advantages of the treatment
as well as the costs would also be material
to the decision.
There are two exceptions to the general
rule of disclosure. The first comes into play
when the patient if unconscious or otherwise
incapable of consenting, and harm from a
failure to treat is imminent and outweighs
any harm threatened by the porposed
treatment. If possible, a relative's consent
should be obtained.
The second exception obtains when the
disclosure about the risk poses such a threat
of detriment to the patient as to become
contra—indicated from a medical point of
view. Occasionally, patients become so ill or
emotionally distraught on disclosure that
they would be incapable of rational decision,
or complicate the treatment. The disclosure '
may even pose psychological damage to the
patient.
Such exceptions, however, do not justify a
paternalistic attitude in normal cases on the
part of the physician. The right of the
patient to make an informed decision should
be safeguarded.
A Verbal explanation may be sufficient, But
to avoid legal complications, a written

JANUARY-FEBRUARY '81

25

health

326. V Mein, I Block
Koramengala
B8ngalore-660Q34
India

ceu

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medical ethics forum-22
FR. GEORGE V. LOBO S.J.

f

Models for a Christian Hospital
it is generally accepted that a Christian
hospital contributes to the healing missions of
the Church. But as the Church herself can be
perceived according to different viewpoints,
the Christian hospitals also will take on diffe
rent forms. The categories are not exclusive;
they overlap to a certain extent. Still, some
’ are more basic and hence it would be help
ful to indentify them. Avery Dulles has dis
covered five different models of the church:
(1) Institution; (2) community; (3) sacrament;
(4) herald; (5) servant (cf. Models of the
Church, Garden City, N. Y., Doubleday,
1974).

X

(1) The Church as a social reality has an
institutional aspect and hence a visible struc
ture without which there would be confusion.
But if this aspect is overemphasised, we have
legalism and institutionalism which stifle her
life and activity. A hospital too needs a
certain amount of organisation in order to
provide effective health care. But if it is
exaggerated, patients will be treated as objects
to be manipulated. There would be no real
healing which consists in reintegration of the
patient’s whole personality. The impersonal
atmosphere will place a heavy strain on the
relationship between the patients and medical
personnel and among the latter themselves.

J

4
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(2) The Church is basically a Community
of mystical fellowship with personal relation
ships among her members. The Christian
hospital too should predominately take on this
note, although organisation and structures
should not be neglected. The healing team,
para medical workers and patients should

j

Nov.-Dec. ’81

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(3) The Church is a sacrament of God’s
love for mankind; her central activity is the
celebrations of the sacraments. The Christian
hospital must also be an efficacious sign of
God ’s salvific and healing love in Jesus Christ.
The celebration of the sacraments of the
Eucharist. Reconciliation and Anointing must
have a vital place in the life of the hospital
community and must be an important element
of the total healing process.
(4) The Church is a kerygmatic community
that proclaims the Word of God, a Word that
witnesses to the saving mystery of Christ.
The Christian hospital in a special way pro
claims and witnesses to the comforting,
healing and saving activity of Christ in the
world today. It should be an inspiration to
other hospitals which are increasingly prone
to have a very mechanistic approach to health
care. The Christian hospital must give a
clear expression to the Christian holistic vision
of health and health care. It should strongly”
witness to human and Christian values which
are expressed in a sane medical ethics. A
genuinely human conception of health care
cannot neglect ethical values.
(Contd. on page 2'1)

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together be regarded as a community, each
one with a personal history and emotional
needs and all called to build up a network of
relationships. All the Christians in the area
must be conscious of their call to be commu
nity of healing in which each member contri
butes to the total healing of the sick members
and others around, each according to his or
her diverse gifts and roles.

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4
Another missionary doctor. Dr. Pfaltzgraf
has aid, “If you are working on mosquitoes
rather than treating ihe child with malaria,
you have failed that mother and her dying
child.”

sets

1 have great respect for these men and
quote them because I know they express the
feelings of many of you. But perhaps we
have been wrong. Dr. Franklin Neva, Associ
ate Professor of Tropical Public Health at
Harvard, says, “What the developing tropical
nations actually need is better nutrition, edu
cation, and preventive medicine : insect con
trol, sanitation, inoculations. The lack of
•preventive medicine so far is a heritage from
the curative medicineminded missionary
doctors. ”

u

u 1

■ ■ • ■!

Perhaps the difficulty in comparing mos
quito work to a child with malaria is that you
can see the child and the mother’s gratitude.
You cannot see the 6 children who might have
been spared malaria with the same investment
of time and talent in mosquito control. Yet
you have failed those 6 to no less an extent.

(Contd. from page 23)

I'

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4Y UMITED

(5) The Church, finally, is a servant of
humanity. Vatican II has recognised the
solidarity of the Church with the whole of
mankind, her sharing its concerns, aspira
tions, anxieties and hopes and its call to put
at its disposal the saving resources which she
has received from her Founder (Const, on the
Church in the Modern World, No. 3). Hence
there should be no element of triumphalism
or rivalry in the activity of the Christian hos
pital whose sole purpose should be to serve
the sick and the sufferent by mediating the
healing power of Jesus. The Christian hospital
should participate in the process of liberation
and achieving social justice in the world today.
Nov.-Dec. ’81

BP ’

I am not impressed by the arguments made
in the last few days that missions have inade
quate money. I am not impressed, however,
if you have money and staff to run a hospital
but cannot get money and staff for communi
ty medicine, because it means the priorities
are wrong. You are not seeing the full picture
of what is happening in the villages. The
question is not, “Can we affor^ to get into
community medicine?” but rather, “Can we
afford to ignore it?”.
■

Ivan Illich, a Catholic priest from Latin
America, has provided a thoughtful review
entitled”. The Need for Counterfoil Resea
rch”. He says, ‘The ploughs of the rich can do
as much harm as their swords”. Perhaps it is
appropriate to say surgery theatres can do
more harm than bombs because it is easier to
create mass demand for the former. The nice
mission with a nice but inappropriate progra
mme is not simply harmless. He goes on to
say we are victims of our environment, of the
institutions we build. Progress to us means
proliferation or expansion of these institu
tions, and as we move to aid developing
areas, we transplant our aspirations.. This can
lead to greater underdevelopment.

For example, a medical centre can become a mecca of quality medickl care, but
what is the price? If $ 100 would save; a life,
we are easily
c—, content to say the cost of saving
a life is $100. But if that $100 had been ins
tead invested in providing safe water supplies
or better nutrition and if it could have saved
10 lives instead of one, then the cost of saving
one life is not simply $100 but is $100 plus 9
deaths. This is the production of underdeve
lopment. In addition, the centre now becomes
a sponge absorbing surrounding medical talent,
either pulling in those from other areas or
preventing them from going to other areas.
This produces medical underdevelopment at
the periphery.
Third, it raises aspirations and fixes the
27

medical ethics forum-21
r

FR. GEORGE V. LOBO S. J.

Helping the Family of Handicapped Child
The family of a congenitally handicapped
child has to face such stressful situation that
many people think in terms of genetic coun
selling with the option of abortion, or even
infanticide. From the Christian standpoint of
the absolute inviolability of human life, this
is not an acceptable solution. On the other
hand, a merely negative stance is not helpful.
The family has the right to receive support
and counselling to cope with the difficult
. /blem.
Counselling is called for as soon as the
defect is recognized. The reactions of the
parents of handicapped children are similar
to those of the bereaved. Most mothers dur
ing pregnancy expect to have a perfect baby,
although there may at times be the fear that
the baby may be defective. The discovery
that the baby or fetus is defective poses two
psychological problems : the loss of the per
fect child which was expected and coming
to terms with, and caring for the defective
child.
There is an intitial stage of denial fallowed
by anger and depression. Only if these feel
ings are properly handled, acceptance follows,
f
)tional turmoil with a sense of disappoint
ment, helplessness and personal failure at
not being able to produce the perfect child
wished for will be experienced. The sur
charge of guilt feeling may make the parents
feel as damaged as the child. For instance,
a mother whose son was born with congeni
tally deformed shoulders might feel that she
caused it because, while pregnant, she had a
fierece argument with her mother-in-law and,
in a rage seized her by the shoulders to shake
her. Such irrational interpretations of what
has happened may result in over-solicitous-

ness or rejection of the child, if not also
anger turned on oneself.
The parents then need to express dis
appointment, guilt and confusion over the
child in an understanding and trusting
atmosphere. The medical personnel who
wish to provide support and clarification
themselves need to be comfortable with their
own feelings. Their anxiety should not lead
to impatience or urging the parents prema
turely to get rid of their negative feelings.
Acceptance of the defective child like the
grieving process takes its own time. At
times a certain undercurrent of chronic
sorrow may remain which will have to be
accepted.
At times the denial may take an extreme
form. Thus a father may sit holding the hand
of a severely retarded son and say cheerfully:
"Joe is such a good little fellow, we'd like
to have another one just like him." When
this happens greater patience and under
standing are needed to help the person to
come to terms with the reality.
Disabled persons are best taken care of
within the home. But others should not
think that it is only a family affair. Parents,
spouses and relatives need help to cope with
the heavy strain which the presence of a
disabled person makes on them. They need
relief from nursing and other tasks. It is very
helpful if people come forward to arrange
joint outings for a group of disabled. Not
only will this strengthen their morale, but
the families will experience some relief on
such occasions.
As there is a tendency to look down on
families that have a seriously disabled or

5.

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(Contd. on page 36)

i!
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JULY-AUGUST '81

■'

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25

'•

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S’1
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conducted by the Assisi Institute for Com
munity Development Kothanur P. 0. Byrathi,
Bangalore. Sr. Isabella Mary is the Adminis
trator of the Institute.
Admission to the above course will start
from October. Those who would like to do
the course, may apply to the Administrator
soon, j
i

medical ethics forum-21
(Continued from page 24)
arded member, they tend to hide the fact
uom the public. The handicapped person is
kept as far as possible out of vision to avoid
embarassment. This results in further aliena
tion for the handicapped person as well as
anxiety for the family. Hence neighbours and
friends should help by genuine understand
ing and sympathy. The handicapped person
should be fully integrated in the parish
community. This should be an inspiration for
non Christians to accept handicapped persons
in society. It should be noted that a group
of persons unable to accept a handicapped
person is itself handicapped.
Help and care of the handicapped is not a
matter of pity but is a fundamental right of
the human person. In order that such a right
be respected there is need for a proper hiera
rchy of values. The respect and dignity of
.man persons, however disabled, takes
precedence over power and productivity. It
is only such an attitude on the part of soci
ety that will help the family and the handi
capped person himself or herself to cope
with the problem.
REPORTS
Reports of your medical works may be
sent to the editor. Medical Service for
favour of publication.

SURGICAL AND
TRAINING CENTRE
INAUGURATED
MRS. RAJI NAMPELI
(Public Relations Officer, Damien Social
Welfare Centre)
Declaring open the Surgical and Training
Centre of Nirmala Hospital, Govindpur, Mr.
R. N. Sharma, Chairman, Coal India Limited,
appreciated greatly the German Leprosy
Relief Association, the chief donor agency
of Damien Social Welfare Centre and appea
led to all the citizens of Dhanbad especially
the public and private sector undertakings to
unite and fight against leprosy. He stated
that this process had to be faster than the
rate of infection of leprosy.
Mr. Sharma commented on the remark
able and dedicated service done by the centre
and earnestly called on all the citizens of
Dhanbad to launch a programme in eradicat
ing leprosy from this area by accelerating the
process which is already started by the
Centre.
Mr. Sharma further emphasised that it is
the responsibility of the people who live in
the district of Dhanbad to see that the
leprosy patients who get cured are able to
retain their jobs or to use their skills. In this
connection he requested the public sector
and private sector undertakings to make all
necessary arrangements to purchase the
items produced by the DSWC Rehabilitation
Centre. He reiterated the need of health
education and removing prejudices about the
diseases from the minds of the people.
Miss Waltraud Kraft, project director of
German Leprosy Relief Association was the
Chief Guest for the function. Dr. P. K. Dutta,
the president of the governing body of DSWC
introduced the guests and Sr. Dorothy,
5

3B

MEDICAL SERVICE

MICRO!

COLOR
FLAME

Tel : 318*
JULY-AUGUST

V

f

ting a more unitary view of the patient
and then establishing a more fully human
relationship with him or her. By this last
I mean a relationship that respect the
connection between the psycho-affective realm
and the suffering body. The relation between
doctor and patient must once again be based
on a dialogue that involves listening, respect
and concern; it must become again an authen
tic encounter of two free human beings or, as
it has been put, between “trust” and “con
science”.
This kind of relationship will enable the
sick to feel that they are being seen for what
they really are : individuals who have diffi
culty using their own bodies and developing
their own powers but whom all the while,
retain intact the innermost essence of their
humanity and whose right to truth and the

good, on both the human and the religious
levels, is to be respected.
Distinguished ladies and gentlemen, as I
propose these reflections, I think spontaneously
of Christ’s words : liI was ill and you comfor
ted me.”2 What a stimulus to this desired
“personalization” of medicine can be found in
Christian charity which causes us to see in the
face of every sick person the adorable face of
the great, mysterious Patient who continues to
suffer in those to whom you give your pru
dent and beneficent professional help.
At this moment I pray to that Sufferer and
I call down abundance of heavenly blessings
on you, your dear ones and all your patients.
As a pledge of these favours I bestow on you,
my heartfelt Apostolic Blessing with its
promise of grace.

I

(LINACRE QUARTERLY AUGUST, 1981, NO. 3)
References
1. John Paul, IT, Encyclical Letter Redemptor Hominis, March 4, 1979 (No. 16 CTPS XXVI, 121-122
2. Mt. 25-26

it
I;

medical ethics forum-24
FR. GEORGE V. LOBO S.J.
Basic Difference between Contraception and
Natural Family Planning
To many minds there seems to be no
ethical difference between contraception and
natural family planning since the end intended
is the same.

But the morality of an action

does not depend only on the end; the morality

of the means also is to be considered. Pope
Paul VI in Humanae Vitae, 1968 had explained
the Church’s stand disapproving of the first
and not the second by saying the teaching
“is founded upon the inseparable connection
willed by God and unable to be broken by

man on his own initiative, between the two

meanings of the conjugal act : the unitive
19

February 1982

1^5*5

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- . .j K- -

meaning and procreative meaning.” (N. 12).
In his recent Apostolic Exhortation on the
Family, Pope John Paul II has developed the
arguement. It is worth quoting the passage
in full : “When couples, by means of recourse
to contraception, separate these two meanings
that God the Creator has inscribed in the
being of man and woman and in the dynamism
of their sexual communion, they act as
‘arbiters’ of the divine plan and they ‘mani
pulate’ and degrade human sexuality—and
with it themselves and their marriage part
ner—by altering its value of ‘total' self-giving.
Thus the innate language that expresses the
total reciprocal self-giving of husband and
wife is overlaid, through contraception, by an
ctively contradictory language, namely,
that of not giving oneself totally to the other.
This leads not only to a positive refusal to be
open to life but also to a falsification of the
inner truth of conjugal love, which is called
upon to give itself in personal totality.
When, instead, by means of recourse to
periods of infertility, the couple respect the
inseparable connection between the unitive
and procreative meanings of human sexuality,
they are acting as ‘ministers’ of God’s plan
and they ‘benefit from’ their sexuality accor
ding to the original dynamism of ‘total’ self
giving, without manipulation or alteration.

In the light of the experience of many
couples and of the data provided by the
different human sciences, theological reflection
ble to perceive and is called to study
further the difference both anthropological
and moral between contraception and recourse
to the rhythm of the cycle : it is a difference
which is much wider and deeper than is usually
thought, one which involves in the final
analysis two irreconciliable concepts of the
human person and human sexuality. The
choice of the natural rhythms involves accep
ting the cycle of the person, that is the woman,
20

All this ct
effort on the
counsellors,
in order “tc
regulating ft
applied.” (f
Exhortation
concerned to
meanwhile, i
will be con
which they

and thereby accepting dialogue, reciprocal
respect, shared responsibility and self-control.
To accept the cycle and enter into dialogue
means to recognize both the spiritual and
corporal character of conjugal love with its
requirement of fidelity. In this context the
couple comes to experience how conjugal
communion is enriched with those values of
tenderness and affection constitute the inner
soul of human sexuality, in its physical dim
ension also. In this way sexuality is respected
and promoted in its truly and fully human
dimension, and is never ‘used as an ‘object
that, by breaking the personal unity of soul
and body, strikes at God ’s creation itself at
the level of the deepest interaction of nature
and person.” (N. 32)
The main point the Pope is making is that
contraception is an attempt to actively
'suppress’ the gift of fertility while natural
family planning is a way of 'recognizing’ and
'respecting it. The first implies an objective
restriction on the total self-giving of the part
ners and violates the integrity of the act of
love. The sign of conjugal love is falsifed to
some extent.

CHAI WE!

The CH
at a two-d
The inaugu
Rt. Rev. z
Calcutta.

However the Pope notes three requirements
for an effective programme of natural family
planning :
(1)

need for understanding its inherent
value and the disvalue in contraception.
A quiet reflection on the above text
should help in this direction.

(2)

making the knowledge of ‘rhythms of
fertility’ accessible to all married
people.

(3)

education in self-control. Chastity is
to be understood, not as “rejection of
sexuality” but rather as “spiritual
energy capable of defending love from
the perils of selfishness and aggressive
ness, and able to advance it towards
its full realization.” (N. 33).
Medical Service

Speakin
in future,
Director of
wholistic c
should be
curative,
include de>

4

He cal
cut down
the mone;
minimised
provided.
Later,
spoke on ‘
Health an
steke. Pro

February

,

reciprocal
self-control,
ito dialogue
ritual and
)ve with its
context the
w conjugal
- values of
e the inner
tysical dimis respected
illy human
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of nature

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ing is that
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ile natural
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the partthe act of
falsifed to

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Jetion of
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ve from
,gressivetowards
I Service

CHAI WEST BENGAL UNIT FORMED

Speaking on the main emphasis of CHAI
in future, Fr. John Vattamattom, Executive
Director of CHAI said that it should be on
wholistic development.
Preventive medicine
should be administered much more than
curative. Community health work must
include development activities.

inher,'nt
race p t ..
bove text

I

He called on large health institutions to
cut down cost of establishments and divert
the money to rural areas. Beds could be
minimised
and better out-patient care
provided.
Later, Mrs. Nupur Sanyai, a social worker,
spoke on “Organising Women in Community
Health and Nutrition.” Dr. Jacques Vuylesteke, Professor of Human Nutrition at the

February 1982

they are not yet able immediately to realize
the norm of openness of every marital act to
live. They are not blameworthy if they
consider that a method other than the natural
is the only way of safeguarding important
values in a given situation. A sincere striving
after the norm and realistic decisions taking
into account all the moral values in the case
is the only way in which the teaching of the
Church can become credible and helpful to
family life.

NEWS

The CHAI West Bengal UNIT was formed
at a two-day meeting on November 14, 1981.
The inaugural session was pressided over by
Rt. Rev. Alan de Lastic, Auxiliary Bishop of
Calcutta.

luirements
*al family

ythms of
married

All this calls fora systematic and vigrous
effort on the part of “doctors, experts, marriage
counsellors, teachers and married couples ”
in order “to make the natural methods of
regulating fertility, known, respected and
applied.” (N. 35). The recent Apostolic
Exhortation then should be a stimulus to all
concerned to work towards this goal. In the
meanwhile, it is obvious that many couples
will be confronted with conflict situations in
which they may conscientiously think that

NOTES

Antwerp Institute of Tropical Medicine,
Belgium also spoke. He stressed that healthy
mother and child relationship was important
for better health. A delicate balance should
be maintained between indigeneous and
modern medicine when administering the latter,
Dr. Jacques said.
In his talk. Dr. S.N. Chowdhury, Director,
Child-in-Need Institute said that, children are
victims of mal-nutrition on account of poyerty,
broken houses, frequent pregnancies among
mothers, large family, choronic infection, etc.
He also highlighted the various programmes
of the Government which include among
others, Special Nutrition Programme (SNP),
Integrated Child Development Service which
covers 10,000 children per block plus pregnant
and lactating mothers, Mother and Child
Care Programme sponsored by UNICEF and
CARE and Balwadi programme.
In the business session, Fr, Francis Gomes,
Sr. Brigid and Fr. P. Stephen were elected
President, Secretary and Treasurer respectively
and Srs. Germaine SMI_and Maria Goretti
as members.
21

•B

B .B Ogt

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frequently

present

in

the

so-called

'indications'

medical, eugenic, economic and social-can exempt
from this positive, obligatory prestation for a long
time, even for the entire duration of the marriage,"
Oct, 29, 1951, AAS (1951) 835-54 at 845-6.
t

3. Ethical and Religious Directives for Catholic
Health Facilities.
4. "Minimal risk" should be understood as equi
valent to normal risk of that age and or capacity of
the individual, for example for children minimal risks
are those "equivalent to the normal risk of childhood"

(Research involving Children, DHEW Publication Nlo.
(OS) 77-0004, p. 137). sc. those encountered in the
daily lives of normal children or in their routine exa
mination. However, it is necessary to keep in mind
that ordinary minimal risks can be heightened by the
condition or institutionalization of the particular
subject.
Under no condition should the dependency state
of mentally
retarded persons be considered a
warranty for their exploitation either in treatment or
research.

Medical Ethics Forum—25
FR GEORGE V LOBO SJ

Morality of amniocentesis
Amniocentesis
is the aspiration of amnio
tic fluid for prenatal diagonistic purposes.
It is mostly done during the 1 2th to the 1 6th
week of pregnancy to detect fetal abnormali
ties or sex-linked disorders. The procedure
is no more experimental since it can now be
used with safety by experienced operators
with adequate equipment. Still, there is
about 1% risk of fetal mortality and hence
it should be used for only serious reasons.
Since 1930, amniocentesis has been
used for the management of Rh disease.
There would be no ethical difficulty in
adopting the procedure to diagnose and treat
this or any other condition in utero, when
there is^some reason to suspect a deformity.
But more recently it is being adopted as
a preliminary to 'genetic counselling' which
practically means varifying fetal abnormaltities with a view to resolving the problem by
abortion.
Current indications for amnioc
entesis include sex-linked disorders. If a
March 1982

mother carries a male fetus, then it has a
50% chance of being defective. There are,
unfortunately, people who would go in for
abortion with a 50% chance of killing a nor
mal child just to avoid the possibility of
having a defective one.
In the ethical judgement on prenatal
diagnosis through amniocentesis, the risk of
fetal loss or still birth must be considered
even though it is not of a high order. All
concerned should understand the limitations
of the method since all birth defects and
mental retardation cannot be excluded, and
that in the case of undiagnosed twins the
result provided would pertain only to one
of the twin pair. If a couple were determi
ned to destroy the life of a fetus that is
known to be defective, they would be incli
ned to kill it all the same after birth if the
defective is not diagnosed by the method.
In fact, 'euthanasia' of defective newborns
is being increasingly reported.
As abortion of a defective fetus is itsel
gravely wrong amniocentesis with an active
31

I

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will to abortion of a defective fetus would
be equally wrong. Even those who favour
abortion 'in the most severe cases' would
have to provide clear criteria for the judge
ment and say who should be responsible for
making it. Once the principle of abortion
is admitted, the couple would suffer a most
painful dilemma when only one member of

lw

a twin pair is affected.
A case for amniocentesis could perhaps
be made when there is risk of defective
offspring and the parents are determined to
go ahead with abortion to eliminate the con
tingency. In such a situation, the one who
performed the procedure would himself/herself not be responsible if they go ahead
with abortion in case the defect is verified.

- <w

If it is not, as is likely in the majority of
cases, the life of the fetus would have been
saved. But there should be no room for
misunderstanding. The health care facility
should try to dissuade the couple from con
templating abortion and make it clear that
it does not itself approve of abortion if defect
is diagnosed.
in India, there is the special problem of
some parents being obsessed with the desire
of having male offspring. Amniocentesis
then can become a tool for eliminating ba
bies of the unwanted female sex by killing
them before they are born. This is a mani
festation of gross male chauvinism and
acquiescence of women in it, besides the
grave evil of abortion.

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| •

medical ethics forum

1

26

PR. GEORGE V. LOBO S.J.
I

i

Ethics of placebos
In ancient times, the medicine— man effec
ted cures by the use of substances which on
scientific basis often have no therapeu
tic effect. It was obviously due to the
power of-suggestion. Nowadays the use of
'placebos' or inert substances has also a
place in modern medicine. A 'placebo',
(literally meaning 'I will please’), may be
defined as a preparation "which has no in
herent pertinent pharmacological activity,
but which is effective only by virtue of the
factor of suggestion attendant upon its
administration".
Such a procedure has obviously an
element of deception, but is not necessarily
deceit, the latter implying blameworthiness.
While the need for' the use of a placebo
reveals diminished sense of responsibility
on the part of the patient, it may be indica
ted in certain circumstances. When the
patient needs support for a strong depen
dency feelings, medication, which is over
the symbol of the doctor's power, may well
have its purpose served by a placebo if there
is no specific drug available. In some situa
tions refusing to prescribe a placebo would
mean saying in effect: "I can't help you
because there is no medicine for your
disease". For some patients, such a communication might be cruel. On the other
hand, the physician should not be so moved
by the placebo effect as to neglect specific
potent medicine when this is available.
The placebo is a research tool of prime
importance. There is no substitute for the
placebo in the 'double-blind' evaluation of
new drugs. But such experimentation should

e

■..

be carried on with due moderation and not
neglecting the interests of the present
patients for the sake of some doubtful future
good. There is also the need for securing
the consent, at least implicit, of the subjects.

■3

A clear indication for placebo occurs in
some patients who have received sedatives
or narcotics which are no more needed. The
substitution of a placebo for a short time
may be a helpful transition to no medicine.
In certain types of incurable disease, the
judicious interpolation of placebos would
decrease the narcotic-sedative requirements.
The overall comfort of the patient wojuld
thereby be enhanced.

I

Occasionally, during a period of diagnos
tic observation or testing, a placebo may
provide a sop to over anxious patients who
demand immediate results.
However, several dangers attendant on
widespread use of placebos must be noted :
(1) reliance on placebo therapy might
strengthen the belief that there is a remedy
for every ailment; (2) patients, and in the
case of children, their parents, might come
to expect quick remedies in every situation;
(3) undue experimentation might spread; (4)
deception might spread to other areas of the
patient-physician relationship; (5) one may
be inclined to perform surgical interventions
like appendectomies or hysterectomies simply
to give the impression that powerful means
are being taken. Similarly, expensive and
potentially dangerous diagnostic procedures
may be adopted to give the patients a sense
that powerful efforts are being made on their
behalf; (6) even inactive placebos can have

July 1982

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27

.....

SOOP
WI

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CHAI

NEWS

I

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NOTES

}| r

School Health Programme of Fr. Muller's Hospital

i

Fr . Muller 's Institutions have started the
second hundred years of their service. With
their sights stead-fastly set on the future,
the hospital's centenary objective is reaching
out to the community, to ensure positive
health for all people. As part of this commu
nity out-reach programme, the hospital has
ventured on a new project involving mainly
the children attending schools and through
them indirectly the members of their respec
tive families.
Gone are the days when hospitals used
to cater only to the sick and the suffering.
(Continued from page 27)
toxic effects like nausea, diarrhoea and
dermatitis; (7) dependency can be created,
the patients becoming addicted or habitua
ted to the point of not being able to func
tion without the placebos; (8) the element
of deception must be seriously considered.
Further, if the patient discovers the ruse, he
may lose confidence in physicians and in
bona fide medication. They may then indulge
in dangerous self-medication.
Genuine health is based on personal
responsibility which must be fostered by
open dialogue and free choice. Placebos
can at best be a temporary support when
the patient is not yet in a position to face
reality fully. It might be useful to cite the
warning of St. Augustine regarding the
danger from the so called white lies; "Little
by little and bit by bits this will grow and by
gradual accessions will slowly increase until
it becomes such a mass of wicked lies that it
will be utterly impossible to find any means
of resisting such a plague grown to huge
proportions through small additions."

Today they have a much boarder view to the
approach to health-care This school health
programme launched by Muller's Institutions
aims at bringing positive health to school
children by making use of the resources of
the school, namely the teachers and the
students themselves. It is well known that
the schools are easily accessible to health
promotion. Yet the majority of school child
ren in many countries are neglected from
the health point of view, because of such
handicaps as lack of personnel and resour
ces.
The conventional school health program
mes are limited to a few favoured schools in
Urban areas, where children are medically
examined with no follow-up action. These
existing programmes are ill adapted imports
There is some
from developed countries.
conventional thinking that health care can be
delivered only by the chosen few who are
qualified by virtue of specific studies like
medicine and nursing. The School Health
Programme which
Muller's Hospital has
ventured on keeps in view all these draw
backs and strives to enable school teachers
and pupils themselves to be deliverers of
health care for themselves as well as for
others. This will be an ongoing programme
in selected schools. On a trial basis only 8
schools have been selected. Other schools,
mainly those belonging to rural areas with
fewer medical facilities, will be its future
concern.
In keeping with the objective, a training
programme for the school teachers of
these schools was organised by the Hospital
from 10-5-1982 to 15-5-1982.
Two or

July 1982

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s i. three teachers from each school were selec
ted. A group of 21 participated in the
course. The course centered mainly on
imparting practical skills and experience to
the teachers in the early detection and
treatment of minor ailments in children as
well as the prevention of communicable and
deficiency diseases and first aid skills.
It also covered certain topics like perso
nal and general hygience, abnormalities in
growth and development of children as well
as nutrition and methods of health education
to pupils. The inauguration of this school
health programme took place on the 10th of
May 1982 at 9.30 a.m. in the Nurse's
Lecture Hall under the presidentship of the
Rt. Rev. Msgr. A.F. D' Souza. The chief
Guest Dr. Miss Olinda Pereira, Principal,
School of Social Work, Roshini Nilaya, in her
address observed that teachers were the
persons who could do much for their stu
dents' health, although they were already
overburdened today with various extracur
ricular tasks such as survey and census.
In his keynote address, Mr. Prabhakar
Alva explained elaborately the meaning,
aims and objectives of the school health
programme, in the light of the W.H.O theme
"Health for all by 2000 A.D.". In his presi
dential address Msgr. D'Souza said that this
programme was of great importance to
today's society, which is still afflicted with
prejudices and false
notions
regarding
health and disease.
It is hoped that this programme, which
is to be introduced in eight schools from the
begining of this academic year, will prosper
with the co-operation of the headmasters,
staff and students of the,schools concerned
and with the goodwill of the public.
(FMC! Bulletin)

NANI Formed
With the aim of promotion and protection
of breast feeding, representatives of Volun
tary Health Association of India, Medico
Friends circle, Indian Federation of Consumer
Organisations, Consumer Guidance Society
of India, and Action India, recently formed
"National Alliance for the Nutrition of Infants
(NANI).
NANI'S plan of action include among
others, pressurising the Government for the
strict implementation of the code of market
ing for the infant foods, discouraging the
authorities of hospitals, clinics and health
centres to entertain the promotional activi
ties of the infants food manufacturing com
panies.

Management course for
Hospital Pharmacists
The Indian Hospital Pharmacists' Associaiton, New Delhi, will conduct its Sixth
Management course for hospital pharma
cists as per details below
: Medical Council of India
building, Kotla Road,

VENUE

New Delhi - 110 002.
: September 20-25, 1982.
!

DATE
WHO CAN
APPLY

FEE

: Hospital Pharmacists, pre
ferably diploma or degree
holders in pharmacy and
engaged in supervisory
position.
: Rs. 200/- Payable by
Demand Draft, drawn in
favour of
‘The Indian
Hospital Pharmacists
Association'.

Hearty congratulations to the authorities
of Fr. Muller's Hospital for initiating this
programme of great importance. Editor
July 1982

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Medical ethics forum—27
FR. GEORGE V. LOBO. S.J.
Will to live versus death wish
The medical personnel, and the wider
human community, are responsible for all
that affects the full personal development of
persons.
However, the primary responsi
bility for a particular person's health rests on
that individual. This fact is clear from the
extremely personal character of health in all
its dimensions. Biological health concerns
that which is most individual and private to
me, namely, my own body. This is even
more so on the psychic and spiritual levels.

I

No one but the person ultimately can
judge his own interior well-being.
The
psychotherapist has constantly to remind the
client: "No one ultimately can help you if
you refuse to help yourself." Even the spiri
tual counsellor must say: "God will help you
with His grace, but you must open yourself
to that grace." Does not Jesus say in
Revelation: "Behold I stand at the door and
knock; if any one hears my voice and opens
the door, I will come in to him and eat with
him, and he with me?" (3:20).

Therefore, whether one is working to
prevent sickness, to maintain optimal health,
to assist recovery from disease or to reha
bilitate oneself after a crippling trauma, a
person must make a commitment to life and
health.
It might seem that no special
commitment needs to be made in this regard
given the innate instinct to survive. But in
the human being, the natural tendency to
live has to be personally ratified. It can
also be frustrated by bitter experiences.
Karl Menninger, for instance, has shown
that suicide is only the last step in an inten
sified process of self-destruction, of hatred
away from external objects and towards the
self. Many have a commitment to death and
not to life.

Healing is a living process that must
occur within the organism. Convalescence
is an active process on the part of the
patient, and staying well is clearly something
that the person alone must do.

In sadomasochistic behaviour, aggressive
action and suffering of pain are invested
with erotic overtones so that suffering and
causing to suffer become pleasurable. In
self-hatred, satisfaction is sought through
self-pity and the craving for attention and
care from others. Some patients seem to
enjoy being sick or least to enjoy constant
complaining, medication and even painful
operations. A life otherwise empty is at
least partly filled with the drama of disease
and therapy.

In a profound way the will to life and
health is the fundamental element in all
healing, and this will must be intelligent,
that is a realistic and wholehearted search
for the means of health. A noted surgeon
once said that he dreaded operating on
patients who doubted their chances of
recovery because in his experience such
patients did not recover. Most doctors and
nurses seem to believe that the 'fighting
spirit’ is a critical factor in favour of recovery.

Such commitment to death means that
everything associated with the medical pro
fession becomes fascinating to some persons
and symbolizes theirown unconscious drives,
not to be healed, but to keep on being sick
in various ways. They may tend to seduce
medical personnel into satisfying their mor
bid needs. They may be tempted to pander
to their needs in order to satisfy their own
need to be needed, if not because of
financial gain.

August 1 982

19

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nature
and

The commitment to life is a marked ele
ment in the Judeo-Christian tradition. "I
have set before you life and death, the
blessing and the curse. Choose life, then,
that you and your descendents might live."
(Deut 30:19). Such a commitment to life
has to proceed from the spiritual level,
although it is normally manifest on all levels
of the personality
But it can be so blocked
that persons profoundly dedicated to life in
their spiritual centre can still suffer from an
unconscious will to death at the psycholo
gical level.
Such a morbid feeling can be rationalized
in the form of Christian mortification. True
Christian mortification is the readiness to
undergo any suffering implied in one's
radical commitment to God and generous
service of neighbour. Even death is to be
welcomed, not because it is a good in itself,
but because it opens the gate to fulness of
life or eternal life. The true Christian attitude
to suffering and death is revealed in the
prayer of Jesus: "Abba, Father, all things
are possible to thee; remove this cup from
me; yet not what I will, but what thou will."
(Mk 14:36). There must be the clear desire
of experiencing healing, if possible of being
physically cured. But as to the latter, if one
has to bear continual disability, one will
experience healing on a deeper level, one
will be able to cope with the condition.

The Christian then should never look
upon disease or death passively, as if they
in themselves were somehow spiritual
goods
It is true that Christian thinking has
often been distorted by false fatalistic notions
surviving from pre-Christian times or inspired
by neurotic abuses of religious symbols.
According to authentic Christian belief, every
individual has a responsibility to choose to
live and to strive towards a full and abun
dant life. He must accept disease and
suffering only as inevitable incidents in the
battle, but not as its final outcome. Christian
acceptance or resignation is not passive
acquiescence, but rather a means by which
good can be brought out of evil.
When one prays for healing, one must
ask for full recovery with all one's heart,
whether this is to be brought about by thera
peutic means or in an extraordinary way.
But one must always add: "Not my will,
but yours be done." Then the prayer will
always be efficacious. It will result in deep
peace and comfort, even when the physical
ailment is not cured.

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The medical personnel should inspire
this will to live in the patients. This can Abe
done only if they themselves have a positive
outlook towards life and real understanding
and sympathy for the patients.

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EMPLOYMENT
Wanted for a rural type hospital at Madar, Ajmer: Rajasthan
an enthusiastic and dedicated Christian
octor who will like to develop a base-hospital of initial 10 beds, and a rural (several villages) health and
medical out-reach program and campus base health and developing work. Salary according to experience
and position, and negotiable. For further information please write to :
James Lail, 4— Battery Lane,
Delhi 110 054. with a copy to Dr. J. I. Khristmukti, MS, Executive Secretaty, Medical Council of MCI
C/o Methodist Hospital, Nrdial 387 001. Gujarat.”
Wanted a paediatrician for a mission hospital. Please contact: Administrator, Nazareth Hospital, Laitumkhrah
Shillong-193 003, Meghalaya.
WANTED a lady doctor to work in a 12 bed hospital. Salary negotiable.
Director, Caritas Mission Hospital, Bhikhiwind. AMRITSAR, PUNJAB.

August 1982

Please contact for details :

[

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Respect Human Life

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— Sr. (Dr.) Catherine Bernard
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The theme of this year's convention “Add
life to years" kept me thinking. I tried to
situate it in the context of the panel dis
cussion topic and these are some of the
questions that crossed my mind:

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does if refer to years of productivity years when man/woman is capable
of earning ? Then what about the
person
who
cannot earn ? The
aged, handicapped, retarded... ?

These and similar questions quickly come
to mind when one takes a pro-life stand.

I
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are we counting
the years only
from birth? Then what about the un
born?

2. is the life we refer to mere 'biologix cal life' briefly termed existence or
survival then what about Human
Life ?
3.

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For well over 5 years I have been acti
vely involved in Human Life issues and for
me 'Respect Life' has been the question of
the value and sanctity of Human Life— a
question
embracing,
primarily
abortion.
Family Planning and Euthanasia. Hence it is
with concern and involvement that I have
become more and more sensitive and invo
lved in Life Issues.
Due to many experiences, observations
and discussions with persons, policy makers,
programme designers, hospital personnel.
Families and Religious— both men and wo
men - my own understanding and insight of
the issue has expanded, my Respect for
Human Life widened, and my position on the
Issues of Human Life and Human Dignity
has taken a definite stand.
November 1982

It is from this vantage point and by
virtue of my involvement and experience
that I share my observations and insights on
the Issue 'Respect Human Life'.
The greatest war of today is the war on
the Unborn— abortion. More than twothirds of mankind now live in countries which
have abandoned the historic protection of
the unborn child and India is one. Accord
ing to the U.N. there are now approximately
55 million killings annually. These figures
are definitely escalating.
The next war equal to the first is contra
ception— Time does not permit discussion
on the subtle connection between contra
ception and abortion; let me merely state
that before abortion comes contraception and
that abortion is only a Symptom of a sick
society— a sexually sick society.

B-

The next attack on life is Euthanasia:Time does not permit me again the recital of
evil effects consequent upon a contracepting
society and legalisation of abortion, ft is
evident that once a society has decided on
abortion for convenience and population
control, then the way is open to euthanasra.
All this springs from the same utilitarian
philosophy and from the same disrespect for
Human Life.
This is in brief the connection between
lack of respect for life within the womb and
this generates a disrespect for all life.
With this background what is our role and
Involvement in these vital issues that deter
mine the future of life and society at large ?
What is our involvement as Religious and
medical personnel contributing to 'Respect
the Dignity and Sanctity of Human Life ?'
33

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Both the Church emphatically calls for and
the demands of the Medical Profession call
us to make a choice— (1) A choice in favour
of life and life-giving options or (2) the
choice of death. This choice needs to be
determined (as I perceive it) not only in
terms of what it does in the present, but
■rather on the present and its consequences
on society at large, and the future of society
in terms of generations...
Our involvement (for Respect Life issues)
demands that we who are involved in health
services assist a woman/man/couple to
appreciate the value and sacredness of life,
and the consequences that result from 'a
lack of clearly informed and understood
options'.

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potential and
respect for life.

authentic

appreciation and

Pinpointing the issue of Natural Family
Planning, I wish to draw your attention to
the vast number of Catholic Hospitals avail
able in the country— yet r the effort and
impact made from them is almost negligible.
The single question that puzzles me is
"What has the Catholic Hospital done for
furthering" a real and authentic Respect for
life programme" through N.F.P. at this point
Tn time, where scientific evidence is avail
able, and the effectiveness and feasibility of
N.F.P. in a developing country/countries is
available, alongside the growing evidences
of
the side - effects
of contraception,
sterilization and abortion on the individual

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If a couple woman is going to be given
the right to choose abortion or contraception,
then she has the right to be provided the
opportunity to base her choice on facts,
rather than mere information ranging from
vague notions, incomplete knowledge, misin
formation and possibly superstitions to in
correct and untrue facts. This is true even
Every
in regard to Natural Family Planning.
woman/couple has the right to be informed
and we who are involved in health care have
the duty and obligation to know the truth of
NFP and communicate it to people— this
presupposes our well and clearly informed
attitude and approach to the issue.
It is very unfortunate at times to experi
ence several of our Catholic hospitals and
dispensaries, known for their quality and
high supportive services and medical care,
and lack a more important need— i.e. Natural
Family Planning as part of their integral
services. They even lack the important need
of having either a doctor, social worker or
nurse explain |to a pregnant mother/couple
the beauty and significance of new life with
in her— this approach lacks the tremendous

and family life.
We
who are
involved
in Catholic
Hospitals cannot afford to remain apathetic,
or arrive at a compromise. A definite stand
has to be taken for/against Fife— a lack of
failure to include and incorporate, a well
informed, authentic and honest N.F.P., pro
gramme into regular health services, contri
butes to a growing increase of women and
couples who resort to contraception, steriliz
ation and abortion. We cannot escape the
responsibility. We really have no alternative
but to face the challenge and meet the de
mands of the apostolate, if it is to be an
authentic service to people.
One of the common objections that is
vocalised is, let the family/married people
promote N.F.P.— its not for us Religious
the question I ask is— Can we draw lines
in terms of ministry ? Line drawing and
measurements take place from our point of
view and convenience— we need to look at
it with the eyes of faith and the needs of
people. We need to feel that sense of
mission and ministry both individually and
collectively.
35

November 1982

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We are called now, more than ever to be
truly advocates of human rights, human
dignity; we are called through the signs of
the times to stand and fight for a philosophy
of life rather than to sit on the side lines
and surrender to a philosophy of death.
Finally, we must never become discour
aged no matter how great the apathy or

opposition. After all God will not ask us
whether we have been successful, only
whether we tried.
God made man, and the greatest gift we
can give to anyone is the experience of being
and becoming alive-for the glory of God
is man fully alive.

3
9

DIPLOMA IN COMMUNITY HEALTH MANAGEMENT
By

VHAI AND RUHSA
First time such course being organised in India
One Academic year and Practicum.
Course Commenses on 15th July 1983.
for receiving application - 31st May 1983.
Last date t_.

For details and prospectus contact:
VHAI
OR
C-14 Community Centre
Safdarjung Dev. Area, New Delhi-110016

November 1 982

RUHSA
North Arcot Dist. T. N. 632201

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Medical ethics forum — 28

■«

Fr. George Lobo, S.J.

Ethical implications in Aging

r

Traditional society held elderly people
in special esteem, but now with the coming
of industrialization and
the
increasing
dominance of economic over other social
factors, the position of the elderly is
becoming more and more precarious. The
modern attitude of individualism makes it
increasingly difficult to accept the losses and
dependence that accompany aging. Loosen
ing of family ties diminishes the motivation
of the younger to care fortheir aged relatives.
Hence the problem of this 'marginal' group
needs urgent attention.
The respect for the autonomy of the
aged is an important factor in the ability to
age with dignity.
The aged should be
allowed to direct their affairs as far as
possible. At every stage of senescence the
ideal is that the aged themselves and their
families foster that range of personal autono
my which still remains to them after their
other losses.

Ar

gn
<y

Basic services should be first attended to.
The preoccupation with advanced techniques
for a few should not lead to the neglect of
elementary treatment for the many poor.
Old people often need simple things for
comfort and healing. They should not be
neglected because of technological bias in
medicine.
Similarly,
rehabilitation
and
quality home care would seem to have the
priority over research and development of
technology for treating catastrophic illness.
Since communication of health informa
tion is critical for fostering autonomy and
personal dignity of old people, reports on

their condition and prognosis ought or
dinarily be made to them fully and directly.
Instead of the elderly infirm finding them
selves in the sick role for an indefinite
period, health professionals should encour
age them to resume as much responsibility as
their condition allows.

B'

When old age brings about irreversible
weakening of physical powers, psychological
and religious growth can still take place.
The many personal crises brought on by
the impairment in old age are to be regarded
as opportunities for such growth.
Simple prudent health measures like
improved nutrition and exercise programmes
should be accorded greater weight than
advanced techniques that may reach only
The
select groups at some future time.
value of intermediate treatments has to be
judged according to the principle of pro
portionality. The development of advanced
prosthetic devices is a more ambiguous
matter. Medicine's capability of preserving
life, even though meaningful existence has
long since ceased, has created situations
in which neither the patient nor the family
is permitted to accept the reality of death.
Techniques like renal dialysis raise difficult
questions of cost-benefit analysis and of
just allocation of scarce resources.
Research and development of anti-aging
techniques or what is called biological
'clock tampering' should take inro account:—
(1) the probable degree of availability of a
particular technique to the general public;(2)
the impact of the technique on the quality of
overall health care in the area; (3) the degree

B
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19

December 1982

K.’.

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institutions
of
dependence on
and technologies; and (4) the utility of the
invention in relation to the general health and
full life of the patient. The evaluation of
such factors will depend on differences in
value judgements concerning the weight
given to the present generation over the
future, the drive for scientific breakthroughs
vis-a-vis the relief of human suffering, and
the balance between health maintenance
and crisis medicine as ideals of health care.

I

deeig;tured for
ndability.
D to tninternet!-'

Significant delays in aging and dying
pose substantive questions about mortality
and human nature itself. The temptation to
direct termination of life (suicide/euthanasia)
is being increasingly felt, although a sane
ethic will take a decisive stand against the
measure.

countrm
it orders.
guidance,
efficient
other
pmer
emat»
or and

The psychological and social impact of
large-scale prolongation of life must also
be considered. Life extension at the far end
of the life cycle could place an immense
financial burden on the middle generation.
It would have had a serious effect on the
demographic policy. Further curtailment of
births to compensate for the life extension
of the elderly will aggravate the birth
control problem.

1

A

Further extension of the life span may
mean a decrease in intergenerational respon
sibility so far a model of altruistic behaviour
and moral obligation.
All this is not to say that a general
extension of human life is bad. On the con
trary, it is in itself a good and desirable

■

project. But it should not be carried out to
or
the detriment of other more urgent g
to the detriment of the quality of life.
In order to extend and improve th^ life
of the general population, as well as of the
now aged, we need to know more about the
multifarious ramifications of aging. However,
since geriatic research involves risks of harm
as well as potential benefits, experimenta
tion with the elderly persons is fraught with
ethical problems. Therapeutic research, in
which investigation occurs coincidentally
with treatment, raises fewer difficulties.
However, nontherapeutic research with the
elderly as subjects involves an inescapable
conflict of values : the potential benefits
for human persons as groups versus respect
for the dignity, security and well-being of
the individual. There is particular need to
protect the rights of those who cannot make
a free decision because of psychic or social
reasons.
The aged are particularly susceptible to
mental illness. But the label 'senile must
as a
not be indiscriminately
applied
means of evading thorough diagnosis and
appropriate treatment. Drugs are not to be
used to pacify, control, or merely treat
symptomatically aged persons with remediable
disorders.
Many Christian 'homes for the aged' are
providing devoted care to those
who
have no other shelter. But there is also
the need for skilled service for those among
them who suffer from marked psychic
disturbance.

aI
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21

December 1982

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Widening horizons-ll
Dear Friends,
In this issue we introduce two books which raise important issues about the
1

crisis in hospital based medical services and the increasing problem of iatrogenicity — or
the disease-producing nature of medical care itself.

IHich is one of the severest critics

of the medical profession and Horrobin attempts an answer to lllich's criticism on behalf

B

of the medical profession.
the crisis at hand.

These two books read together gives us a balanced view of

The next two books are more personalised approaches by two committed Christian
doctors to find answers to the problems of providing hospital service and health care
programmes to communities where poverty is an increasing constraint.
reach out to the community ?

How do we reorder our priorities ?

How do hospitals

«

Their experience and

suggestions will be most relevant and thought-provoking for all our C H A members.
RAVI NARAYAN

Limits to medicine—medicai nemesis

IB

Ivan IHich, Penguin Books (Pelican 1977)
The foremost critic of trends in modern
medical practice, IHich presents thought
provoking evidence that 'the medical esta
blishment has become a major threat to health
and the disabling impact of professional
control over medicine has reached the pro
portions of an epidemic'. Discussing iatro
genesis in great detail, IHich makes one of
the most forthright pleas for 'demystification
of medical matters' and exhorts lay people
to reclaim greater autonomy over health
decision making. He writes that 'A pro
fessional and physician-based health-care
system that has grown beyond critical bounds
is sickening for three reasons: it must produce
clinical damage that outweighs its potential
benefits; it cannot but enhance even as it
obscures the political conditions that render
society unhealthy; and it tends to mystify
and expropriate the power of the individual
to heal himself and to shape his or her own
environment. The medical and para-medical
monopoly over hygienic methodology and
22

technology is a glaring example of the poli
tical misuse of scientific achievement to
strengthen industrial rather than personal
growth.
The book is divided into four parts
and deals with Clinical Iatrogenesis in Part I,
Social Iatrogenesis (medicalisation of life) in
Part II, Cultural Iatrogenesis (disabling impact
of medical ideology on personal stamina) in
Part III and The Politics of Health in Part IV.
Interestingly IHich warns that 'if contemporary
medicine aims at making it unnecessary for
people to feel or to heal, eco-medicine
promises to meet their alienated desire for a
plastic womb'. He also warns that gullible
patients should not be relieved of the blame
for their therapeutic greed by making phy
sicians scapegoats.

I

I

Health must be seen as

a virtue, as a right and people must be invol
ved in 'political action reinforcing an ethical
awakening — that will limit medical therapies
because they want to conserve their oppor
tunities and powers to heal'.
Medicai Service

1

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I

Medical hubris—a reply to Ivan lllich

it

David Horrobin, Churchill Livingstone, 1978
e

This book should be read after the earlier
one since it is the first serious critique of
lllich's book. Horrobin does not dispute the
facts presented by lllich, but disputes his
interpretation. In spite of all the inaccuracies
and exaggerations in lllich's books that he
attempts to point out, he concedes that
lllich's first sentence 'The medical establish
ment has become a major threat to health'
is right and that this book could prove to be
'one of the key medical documents of the
second half of the twentieth century'.

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In a very open and level-headed assess
ment of the criticisms of Modern Medical
Practice the author gives his own tentative
suggestions to bring about a change in
this situation. He makes a plea for
a)

Dlito
nal
arts
t I,
in
act
< in
IV.
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for
ine
r a
ble
me
hy-

b)

c)

Attempts to be made to keep meciicai
institutions as small as possible and
only for those who strictly need them.

d)

Assess professional training and
prescribe levels of training actually
required to enable people to do jobs
effectively and cut out unjustifiable
part of courses.

e)

Challenge the discrepancy between
the high ideals which doctors often
profess and their personal life styles
and ensure that the profession should
be more humane and /ess a 'certain
road to wealth and security'4- so
that the rightly-motivated people are
attracted to it.

More "Science" in medicine 'to eli
minate the errors encouraged by
warm emotion' that 'to do something
must always be better than to do
nothing'.

These changes should be made at four
main levels: of the individual doctor; of the
organisation of the profession; of the rela
tionship between government and medicine
and medicine-related industries; and of the

Less use of technology by subjecting
them to stricter control to determine
whether they really
benefit the
patient.

medical school.
— A book which puts lllich's criticisms in
proper perspective.

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December 1982

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Respect for Life—Theological Aspects

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Traditional society lived by norms which
apparently were satisfactory in a static situa
tion. Now with ever new develoments, these
norms are being widely questioned so that
there is a sort of polarization between those
who support traditional normsand those who
oppose them! Such a problem can be resol
ved only by goingb eyond the norms to the
values underlying them. Thus, as Prof VV
John, in his keynote address, remarked, "ulti
mately every question is a theological ques
tion." The stand one takes regarding euthan
asia, abortion and other bioethical questions
will in the last resort depend on one's con
ception of human life. Likewise, the type of
health care provided to the people will
depend on whether one's basic motivation is
respect for human life or a technological and
commercial mentality in which health care
becomes an industry instead of a mission.

His sovereign prerogative and hence no one
may anticipate it.

Value of Human Life

All human life is basically equal in value
as all men and women have been made in
the image of God. There is no such thing as
a valueless life whether in the beginning or
end of earthly existence. Even in extreme
decrepitude, suffering or abandonment, life
is still of great value. Personhood is never
lost for the believer looks forward to conti
nuing personhood in eternal life.

The Bible, while admitting man's solidarity
with animal creation, stresses the special
dignity of man. There is a warmly personal
note in the way God breathes into his nostrils
the breath of life (Gen 2:7 in the Hebrew
text). It is an act of self-giving, not only of
creating.

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All human life is a gift of God who is
sovereign in the whole process fron concep
tion until the withdrawl of breath in death.
It is Yahweh who "kills and makes alive"
(Dt 32:19). Hence man has no absolute
sovereignty but only stewardship over human
life which is entrusted (given in trust) by
God.
Earthly life is very precious since it is the
time of favour in which man is tested and
tried. While on earth, each person has a
unique role to fulfil. Yet bodily life is not the
supreme good. The fulness of life is reached
in eternal life after death. Earthly life is
meant to be spent in the service of God and
neighbour. One should not cling to it in such
a way that it becomes an obstacle to the
vocation of love and service.

Human life bears the stamp of the God
who makes man to His image (Gen 1:27).
The psalmist is overcome with wonder at the
mystery of man who was made "a little less
than God, crowned with honour and glory/'
(1:5).

Thus according to the Bible, life is not
mere vital existence, but growth into fulness
of goodness and blessing which come from
fidelity to God. Human life is not primarily
a biological reality; it has an ethical and reli
gious value.

God has steadfast love and care for man
which reveals a special relation to God (Cf.
Ps 8:4; Job 10:12). It is God who takes
away his vital nephesh (Ps 104; 28ff). It is

Christ came that "men have life and may
have it abundantly." (Jn 10:10). While
bringing to fulfilment all that is human. He
also brings eternal life. He appears as the
25-

November 1982

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master Healer, the divine physician in order
to heal all the ailments of body, mind and
spirit. He thus comes to save and enhance
the quality of life at every level.

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Quality of Life
-

Human life is more than a vital force or
physical or biological reality. It is more than
a certain capacity for technical or social fun
ctions. The quality of life has to be measured,
not only according to bodily integrity or
emotional balance, but also according to
religious and moral maturity, althouth the
first two facilitate the last.

■ kJ

Health, therefore, must be understood
according to a comprehensive or holistic con
cept as a well-being on all these levels as
well as harmonious relationship with others.
The healing ministry should be concerned
with all these aspects. There has to be a
certain degree of specialization, but this must
be integrated in a coordinated whole.

di

Euthanasia Against the Quality of Life

Ki

Because of the intrinsic value of human life
it can never be said that someone is not a
human person because he is in a state of
extreme distress or degradation. Even irrever
sible coma does not imply loss of person
hood for the person's spiritual destiny is still
intact.

i

’ Doctors wilt be slow in declaring that
'nothing can be done' to save life since there
is often the possibility of arrest or remission
of the disease. Even when curative treatment
is not indicated, supportive treatment is to be
given. When death seems inevitable, every
thing still can and needs to be done to help
the person during the crucial moment of
passing from this world to the next. The
real question is not whether the suffering
and dying are persons, but whether we are
the kind of persons who will care for them

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without doubting their worth. Hidden behind
the apparent compassion that would seem to
justify euthanasia may be the unwillingness
to care for someone whose life seems to be
useless. On the other hand, proper tender
loving care and skilled nursing and appro
priate relief pain can enhance the quality of
life of the dying patient as well as of those
who give such care.

!

I

Responsible Stewardship of Life
As responsible stewards we have a duty
to take reasonable care of our health and the
means of preserving or prolonging life. The
fact that a much needed treatment may not
be available to the poor raises the difficult
questions: 'Whom shall we serve?' and "How
shall we serve?". There should be an equi
table distribution of sparse medical resources.
The question should be seriously raised
whether enormous amounts should be spent
on procedures that benefit only a few, and
that too not too significantly, when many
more could benefit much more from preven
tive care, health education and primary health
care.

I

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Although no one has the right to diredtly
terminate the life of a person under any
circumstance, still one is not normally obliged
to use extraordinary means of saving or pro
longing life. One must carefully distinguish
the efforts to prolong life from frantic efforts
to prolong the process of dying. One has
not only a right to live, but also a right to
die well.

1

An excessive striving ro prolong life be
cause of not being able to face up to the
issue of death may only bring about greater
disillusionment. When man declares uncon
ditional war on death with all the parapher
nalia of modern gagdetry and technology, he
is absolutely dismayed when he ultimately
fails as is bound to happen. On the other
hand, recognizing the invitation to unbreak-

26

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able fellowship with God suggests that death
is an event in life marking a transition rather
than a terminus. It is not the ultimate disas
ter, but in fact the way to final fulfilment.
Nowadays, social awareness also raises
the question of the responsibility for mass
deaths through malnutrition, unhygienic living
conditions and the lack of essential and
simple medicines. While it is good to be
alert to the question of individual euthanasia,
one must be much more conscious of the
enormous problem of mass or social euthan
asia and seek to find remedies for it.
Management of Pain
A deeper understanding of pain might
help in clarifying the issue of euthanasia in
intractable pain in such conditions as terminal
cancer. Pain is a phychic response to a
stimlus that is generally physical. It may be
handled by trying to suppress it while it is
more important to learn to cope with it.
Artificially induced insensibility, unawareness
and unconsciousness is not always the best
way of enhancing the quality of life in diffi
cult situations. If a headache is set off by
the tension induced by the inability to cope
with life problems, nothing is solved by tem
porarily suppressing the pain by means of
analgesics. The dependence on drugs may
also induce addiction.
We must attend, not only to the nature of
the pain on the physical level, but also to its
implications for the individual. The patient
must feel accepted and cared for since every
kind of pain is intensified by isolation. There
is need for handling fear of oncoming pain by
reassurance. Hence drugs can only be one
of the means to cope with pain.
Abortion and Quality of Life
Personhood does not basically depend on
the stage of development of human life or on
any accidental quality. The special care God
has for the infant in the womb is vividly
described in the Bible (cf. Job 10: 10—12;
Ps 139: 13—16). We see in these passages
November 1982

that God is sovereign in shaping the physicaF
form as well as the life destiny of the child
already existing, but yet to be born.
Respect for life demands that it be regarded with reverence in its weaker forms,. But
we should note that abortion may be logical
in a world that tolerates racial discrimination,
caste oppression and mass killing in senseless
wars like that of Vietnam.
Those who seek to enhance the quality of
human life by destroying the life of weaker
human beings for any cause are only con
tributing to the deterioration of the moral
quality of human life.

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Patient as Person
Every man or woman is a person, not a
thing. Hence therapy cannot be conducted
like repairing a broken down machine. Mani
pulative techniques that jeopardize the free
dom of people should be shunned.
The patient must be treated as a partner
in the process of healing. His informed con
sent. should be obtained, as far as possible for
every serious procedure so that he is jactively
able to respond to the treatment and so that he
is able to make responsible choices regarding
the consequences of the treatment. If some
patients have partially lost the exercise of
freedom through alcoholism or drug addictioh,
the main aim of the treatment should be to
restore the sense of personal dignity and
freedom.
Medical experimentation should not imply
manipulation of the human person, although
there is an element of functional manipula
tion in any experimentation. The patient
should always be treated with respect and
never as an object that is mechanically hand
/
led.
Conclusion
The aim of all medical treatment is to pre
serve or enhance the quality of human life.
But this quality is to be viewed according to
the total vocation of man and not merely
according to a materialistic or functional calL
cuius. This raises several ethical problems.
They have to be resolved having this integral
vision in mind lest attempting to improve the
quality of life in fact should lead to its deter
ioration.

27

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Pro-Life Movement : With Special Reference to
Psychological Aspects

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— Dr. M. John type, Vellore

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If you go to a hospital, you may not find
an abortion case. You may find MTP cases.
What is MTP? Many do not know what
it is. The name is changed to fool the pub
lic. MTP is nothing but, abortion— Medical
Termination of Pregnancy. Termination of
pregnancies are done mostly without any
medical causes. MTP
also stands for
'Murder of Tiny Persons'. Abortion gives a
guilty impression. Hence instruction is to
use the word— MTP— always.
LIFE BEGINS FROM THE MOMENT OF
CONCEPTION. This has been approved by
the world conference of doctors, Geneva con
ference on Human
rights. United nations
charter etc. Your height, gait, finger prints,
I.Q., blood group, identification marks, sex,
etc. are fixed at the moment when the ovum
unites with the sperm— the time of con
ception. If you are going to get blood
pressure at the 50th year, it will be coded
then in the chromosome. If,
Diabetes at
the 40th year, that also will be fixed there,
which nobody can change. These basic
facts are suppressed now.
Many say there is no life in the womb.
Some doctors say life comes after 3 months
after conception/others 6 months after/and
yet others after delivery. The famous doctor
Watson, a nobel prize winner, says life
begins after 3 days after delivery. There
are
famous pediatricians in Europe and
America who feel that life begins after
30 days after delivery.

I
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Circusmen fool the lion and tiger and
make them do as the owner likes it. Just
like this public are fooled by these people.

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to do as desired by these few men. They
misguide and brainwash everybody. They
say they are doing great national service,
by killing the unborn and reducing the popu
lation. But what induces them is money
and this truth is concealed. An agent
who brings a case for MTP and sterilisation
gets Rs. 10/- the patient gets Rs. 100/or 200/- according to the state she lives;
the surgeon gets Rs. 5/- the anaesthetist Rs.
3/- the nurse Re 1/- and the stretcher bearer/
barber/dhoby/instrument bearer etc. all get
Rs. 0.25 each. This whole gang, brainwash
the mothers for getting money in different
ways.

£

Abortion is not a religious question—it is
a question of who lives or dies. Abortion
is not a family matter or a personal matter—
it is a question of who lives or dies. The
aim of abortion is to kilt the baby.
Alec Bourne wanted to legalise abortion.
He did abortion on a lady and was jailed in
England. The movement gained momentum
and abortion was
legalised in England.
Afterwards seeing the millions of abortions
being done— and seeing that more abor
tions occurring than normal deliveries— he
changed his mind. He is now the leader
of the anti-abortion movement in England.
These aborted babies are taken to labor
atories and they inject poison virus or
bacteria and observe how they suffer/ deve
lop fits/struggle and die. There is no restri
ction on this and it is being done even
today, and there is nobody to raise voice
against this crime. Hitler was doing experi
ments on adults, and now we do on babies.
Hitler was condemned, but now these child

November 1982

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Medical Ethics Forum-36
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Ethical Problems of Drug Prescription

3) The personal model of healing is
being replaced by the manipulation of be

Drugs are supposed to be prescribed for
healing or
beneficent purpose. But the
harm done to the patient by the increasing
over-pricing, over-prescribing and misprescri
bing of drugs is becoming manifest. The
purpose of this short paper is to uncover the
reasons behind this unfortunate situation so
that effective remedies may be found to
tackle it.
»

patients2.
Instead of personal dialogue
concerning the deeper cause of the distress,
trust is placed on the efficacy of bio-chemi
stry. The concentration is on artificial labels
of sickness to be treated by mechani cal
means. The value-free or
vaiue-oeutiral
model of science derived from physics and
chemistry is quite appropriate when it strictly
confines itself to these disciplines. But it
acquires a dangerous tone when the mapipulation freely extends to the sphere of
human life. Man the manipulator ultimately
ends up being man the manipulated. Human
intervention, instead of serving the true
interests of man, tends the violation of basic
human values and rights.

1) Modern life is being increasingly
regulated by the technological mode!1.
Instead of technology being at the service of
man, man is being ruled by. technology. The
technical order, in the first flush of its
success, is entering into every nook and
crany of our life and seems to brook no in
herent limitations. Thus human existence
seems to be moving from qualitative progress
to mere quantitative development which has
little use for basic human values that cannot
be measured on the quantitative scale of
external results.

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77

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2) This has an effect on the understand
ing of health, disease and healing. Instan
taneous cure of the symptoms is becoming
the goal of medical procedures.
The
search is for wonder drugs which can provide
quick relief, but leaving the underlying cause ''
of the disease untouched or even aggravating
it. The apparent efficacy of drugs leaves
behind a host of what are called 'side effects'
when often they become the malignant 'main
effects'. Thus we
have
an
increasing
number of 'iatrogenetic' (doctor induced)
diseases.2
3

October-November 1984

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4) The primitive witch doctor sought to
create an air of mystrification by his magical
incantations. The modern therapist creates
a similar effect by prescribing exotic drugs
with esoteric names and whose action le
himself scarcely understands.
5) Modern life tends to reduce the
capacity of man to cope with pain and other
forms of distress. Hence the desire for
quick relief. The patient looks for magi
cal results and seeks out those who wfilf
provide them. The physician is tempted to
yield to this irrational urge without payirlg
sufficient attention to the long term conse
quences. There is thus a vicious circle of
mutual manipulation which diminishes tf)e
humanity of the patient as well as the medicpl
practitioner.

19

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6) The capitalist system with its insis
tence on the 'profit motive' and 'free enter
prise' leads the multinationals and local big
firms to exploit the consumer without caring
for his true interests. While the pharmaceu
tical industry is meant to cater to the health
needs of the people, the people become
means of easy enrichment. Human persons
become a means instead of being an end.
7) The deep rooted cultural alienation,
which
is an
aftermath of colonialism
and one of the more pernicious manifesta
tions of neocolonialism, produces a glamour
for everything that is foreign The educated
and even the neoliterate regard with awe
the modern system of medicine because of
its aline origin and with diffidence, if not
contempt, at systems that are indigenous.
Hence the uncritical acceptance of potent
allopathic drugs and the equally uncritical
rejection of local remedies. Superficial fasci
nation for modern life enables drug compa
nies to push their products by cosmetic
embellishment and elegant packing for which
the poor consumer has to pay heavily.
8) The dependent status of develop
ing countries enables the multinationals to
put undue pressure on the local authorities
to permit their
nefarious activities. The
multinationals find a ready ally in local big
firms even when their commercial interests
may to a certain extent clash. Thereby,
drugs that are unproved in the country of
origin or even those that have been proved
dangerous or ineffective can be pushed with
impunity. The whole matter can be mysti
fied by false claims like of special 'bio
availability'. Any attempt at regulating the
distribution and use of drugs or of banning
dangerous ones can be countered by visible
and invisible pressures with the connivance
of alienated specialists. The present craze
for uncritical opposition to all gevernmental
policies contributes to governmental inaction.

20

9) One of the consequences of mechanization of health care is that initiative in
drug development —»
has passed from the
medical professioni 1to the pharmaceutical
industry. Traditionally pharmacy/ was sub
ordinate to the physician, f
Now the physician
is constrained to perform the
'
...j |pharmacologicaj task assigned them by the drug industry.
The inadequate pharmacological education
of the medical school graduate does hot
provide the background to examine critically
the claims of the industry for its |products.
Even research is often influencedI by the
interests of the drug
i ’
Medical
industry.
journals become the vehicle
.-.a of promoting
the same interests. Companies
Cuinpanies use
use them
them as
advertising media overwhelming the physician not only with publicity, but also with
article after article on the product that is
being promotec at the time. Thus they
hinder legitimate scientific enquiry by plac ng
articles designed to reflect industry views
10) Bourgeois
competitive values in
duce the physicians to seek the maximum
advantage. Not only are they misinformed
by cleverly prepared and attractively got up
brochures regarding the efficacy of the drugs,
but they are influenced by physician samples,
(often sold), and other forms of inducements
like
and
.i pens, diaries
--------j even conference attendence costs. It is indeed a sad fact that the
continuing education of doctors is Ilargely
carried on by medical representatives ;and
their information material containing a lot of
half-truths. Besides, an undue desire for
_
gain leads the physician to neglect the pin
pointing of the disease and to prefer 'fixed
combination' anti-biotics and 'broad spect
rum drugs to take care of multiple eventua
lities and thus be able to process a large
number of cases during a working day.
Thus there is an unhealthy and in many ways
corrupt relationship between the medical
profession and the drug industry.

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Medical Service

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11) On the other hand, research on the
therapeutic value of medicinal herbs and
roots,
presented in some rare journals,
collects dust in reference libraries. However,
fortunately, the healing value of non drug
therapies like Yoga, Pranayama, Meditation
and Accupuncture is be ng increasingly
recognized. Strangely, these
are being
patronized by the well-to-do than by the
poor.

7

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13) The technological mentality also
leads to the transgression of the legitimate
bounds of human experimentation. It is
not permissible to use a drug unless it has
been sufficiently tested in the laboratory and
on animals. Further, an experimental drug
may not be used when a certainly effective
remedy is available, the risk is proportionately
tolerable and there is at least the reasonably
presumed consent of the patient. The prac
tice of trying out experimental drugs on
patients in poorer countries is to be condem
ned as a grave offence against humanity.4

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12) The technological and manipulative
mentality i s a block against the promotion of
preventive health. It is yet to be fully reali
zed that clean water is much more important
than anti-biotics, wholesome food than
vitamin pills, vaccination than expensive
drugs or gadgets.

I

The Remedy
The very exposition of these evils regard
ing drug prescription suggests a programme

1) There is need of evolving a more
humane and person-centred approach to
healthcare. This should above all seek the
true interests of the patients. For this the
time honoured principles of totality and of
double effect must be clearly understood and
applied.

r, 7

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2) The physician must regain the auto
nomy and ideals of his noble profession.
3) Cultural alienation and political inter
ference of foreign powers must be unmasked
and vigorously countered.

I-

4) There is need for counteracting the
pernicious aspects of materialism and capitalism.
5) There should be a massive movement
against the manipulation of drug companies.
While the more immediate perspective of
abuses in the field of drugs must be attended
to, the deeper political and cultural roots of
the problem need to be tackled.

B-"'
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6) The well-intentioned efforts of the
government to check the abuses in the pro
duction, distribution and use of drugs need
to be supported.

1.

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7) Especially urgent is the effort to
reduce prescription to roughly 200 essential
drugs (WHO estimate) with generic names so
that low cost, efficient and safe drugs are
available to everyone.

Hi I R;

i

See Willaim Barett The Illusion of Technique, Garden City, N.Y. Anchor Press. 1978.

I

For Clinical Iatrogenesis and the Medicalization of Life, see Ivan lllich, Limits to
Medicine, Calcutta, Rupa, 1977.
3. Concerning the modern tendency to manupulate human beings, see Bernard
Haring, Manipulation, Slough St. Paul Publications, 1975.

ays
al

4.

I

For a more complete treatment of ethical principles regarding Medical Experi
mentation, see my book. Current Problems in Medical Ethics, 3rd ed., 1980. pp. 100-105.

21

October-November 1984

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: ■ '7 v

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2.

:e

ft

to combat them. However, some of these
will be here briefly mentioned.

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Medical ethics forum - 29
Fr. George Lobo, S.J.
Sex Change
I. An unusual combination of constitu
tional and hormonal factors during prenatal
development can give rise to various types
of bisexual and intersexual anomalies in the
generative system. An individual possessing
characteristics of both the sexes is called a
hermaphrodite.

1
Im

d
1

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1J J

r

1,
I
a

A perfect hermaphrodite is one possess
ing all the generative organs, properly
developed, of both male and female, so
that the person could generate, at least
copulate, either as a male or as a female.
The existence of such a human being is
generally doubted, although some cases have
been reported.
True hermaphrodites are persons in whom
there is an actual consistence of male or
female glands, neither fully developed, but
each present to such an extent that it is
impossible to determine whether the person
is male or female. Some individuals have
gonads composed of a mosaic of genetically
male and female cells.
Pseudo hermaphrodites are described as
persons in whom secondary male characteri
stics are superimposed on a genitic female, or
vice versa, also those who possess some
rudimentary organs of the other sex.
It is not easy to determine which chara
cteristic defines the sex of an individual.
In fact, five categories have been identified—
(1) chromosomal configuration (XX or XY);
(2) gonadal sex (presence of ovaries or
testes) (3) hormonal sex (androgen or
estrogen dominance; (4) internal reproduc
tive structure; (5) external genitalia.

Every human being has a right to belong
to one sex or other. Hence the action of a
surgeon who helps by his art those who wish
to escape from sexual indetermination is
perfectly justified.

Ident

In case where the sex variables are totally
equivocal the corrective approach may be
toward either sex, depending upon the choice
of the individual or, in case of infants, the
determination of the parents in consultation
with the specialist. The earlier the interven
tion is made the better.

reass
Meyc
numt
fema
with
is

Where one sex is identified as predomin
antly determined, corrective measures must
be in the direction of the determined sex.
II. Trans sexualism poses a more ticklish
problem. It is a condition in which biological
sex is clearly determined, but the individual
has a strong psychological identification with
the other sex. When the desire of the
person to live and function according to the
sex of choice becomes overwhelming, the
practice of transsexual surgery or 'sexual
reassignment' is becoming increasingly com
mon. About nine out of ten of the people
who desire the change are men or as they
themselves put it 'women in a male body'.
The patient's sexual organs are restructured
to resemble those of the other gender. The
change is reinforced by massive doses of
synthetic hormones. However, a complete
change in physical gender is not achieved.
The male transsexual transformed into a
female can neither ovulate nor conceive.
Such a procedure is at times justified
under the principle of totality, viz. the
operation is said to be conducive to the total
good of the person. But it is open to serious
ethical objections.
Medical Service

22

betra
in wf
the
the
true |
the p
even

tl

expe
sexu.
mane
fanta

My s
On tf
My f
Had

*T

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i

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My fi
To to
My r<
The s
My G
Reco
My G
Unse
My li
The c
For I
A fru
Janu

1
s

I
9
a
;h
is

To talk of a 'woman in a male body'
betrays a strong dualistic conception of man
in which the soul would be imprisoned in
the body. Some are too prone to admit
the possibility that a person can have the
true psychological identity of one sex and
the physical body of the other. However,
even a person like the director of the Gender
Identity Clinic, a renowned centre

ly
>e
:e
le
m
i-

reassignment

in

the

Meyer (1974) states :

United

for sexual

States, J.K.

"I have

seen any

number of men who would like to live as
female and v/ce versa; I have never seen one
with a reversal of core

|

i-

is

then

gender identity."

very unlikely that

persons

It

who

. experience psychic anguish because of the

st

sexual

•'
>h
al
al
th
le
le
le
al

incongruence can ever achieve per

manent relief by an effort to realize their
fantasies.

Transsexualism is a grave and painful
illusion often arising from childhood, trauma
or parental influence. It calls for much com
passion. Every effort should be made to
bring about readjustment through psychiatric
care. When this does not produce significant
improvement, one may be inclined to approve
of surgical intervention, hoping that the
person would thereby suffer less from
internal conflict and be better able to adjust
to society. But really it would be to yield
to the neurotic illusion of the patient rather
than attempt to ameliorate his condition.
It would imply a gross form of mutilation or
destruction of the bodily integrity of the
individual.
Besides, a functioning male
organ has not yet been developed. The
newly-created 'female' would be rendered
sterile.
In this latter case, ecclesiastical
jurisprudence considers the person incapable
of valid marriage

THE BALLAD OF THE UNBORN

le

2d
te
of
te
d.
a

s

3d
ie
al
us

My shining feet will never run
On the early morning lawn
My feet were crushed before they
Had chanced to greet the dawn.

My eyes will never scan the sky
For my high-flying kites;
For when still blind, destroyed were they
In the black womb of night.

My fingers now will never stretch
To touch the winning tape;
My race was done before I learned
The smallest steps to take.

I'll never stand upon a hill
Spring winds in my hair
Aborted winds of thought closed
On motherhood a despair.

My Growing height will never be
Recorded on the wall
My Growth was stopped when I was still
Unseen, and very small.

I will never walk the shores of life
Or know the tides of time;
For I was coming but UNLOVED,
And that's my only crime.

My lips and tongue never taste
The good fruits of the earth;
For I myself was judged to be
A fruit of little worth.

oe

January 1983

—

H.F.D.s.
(Courtesy Crest)

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— Fr. George Lobo, S.J.

e

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Blood Transfusion
Blood transfusion replenishes depleted
blood volume as in cases of haemorrhage,
burns and shock during surgery, or corrects
blood disorders as in anemia, leukemia,
hemophilia, and immune deficiencies. In many
instances this is a life-saving device without
notable harm to the donor. But efforts to
meet the demand for blood have to deal
with the constraints of short storage life,
safety limits for repeated donations, and
exclusion of potential donors to protect
recipients from blood transmissible diseases,
notably serum hepatitis.
In many countries blood transfusion meets
with difficulties arising from religio-cultural
attitudes like in the case of Jehovah's
witnesses or from those opposed to the
mingling of racially different blood. Fortu
nately, such problems are less encountered
[in India in spite of society being so tradition
bound.

:•

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Here the problem is mainly regarding the
social organisation of blood supply. Ques
tions of distributive justice and social solida
rity are acute. There are three main systems
of organisation
1 )Cash system. At first sight this looks
quite equitable since the donor is comp
ensated for the gift. But here the poor be
come the major suppliers since the cash
motive touches them most. Yet they are the
least able to afford blood when they thems-

February 1983

elves need it, because the cost of comme-!
rcially purchased blood is many times higher
than blood supplied
through voluntary
unpaid donor systems or the compensation
which they received when they donated
blood.
2) Pooling of blood for a group. Here
the spread of the burden is more equitable,
and added costs are less than those of cash
systems.
3) However, voluntary unpaid systems
are the best. The benefit of blood transfusion
is most widely accessible and at the least
cost. The blood supplies are also of higher
quality. In cash systems, a large part of the
supply often comes from people who are
infected with hepatitis since they have an
interest in hiding a fact that would disqualify
them from selling blood. Voluntary unpaid
systems promote social solidarity by provi
ding the occasion for genuine altruism.
According to the general principles of
medical ethics, the handling, processing
and administration of blood and blood pro
ducts must be done with great care in order
to avoid injury to recipients. This care is
needed specially in blood group identifi
cation, screening for contaminated blood,
cross-matching, labelling and patient identi
fication. Similar care must be taken to protect
donors from excessive giving of blood,
infection, and any postdonation hazards
which are all greater in the cash systems of
procuring blood.

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by Fr. George V. Lobo. S.J.
Medicine as Profession
Common usage today applies the term
profession to any activity that-is done compatently. If one is trained
----- 1 for a job and
does it well we say:
"He or she is a
professional." This use distinguishes such
activity from that of the
amateur who often
does not get paid for the activity
/ and is also,
less skilled' as compared to the professional
While this iusage may be valid, it would be
helpful to see the deeper meaning of the
word, especially
as it applies to the
traditionally
respected
professions
like
medicine and law.

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A medical professional is not only
specially skilled. He makes public profession
of a devotion to his particular sphere of acti
vity. He or she knowingly and freely profes
ses his/her devotion to the task of healing.
This has oeen well expressed in a recent
article : "It is a matter not only of the mind
and hand but also of the heart, not only
of intellect and skill but also of character
For it is only as a member of a community
and as a being willing and able to devote
himself to others and to serve some higher
good that a man makes a public confession
of his way of life. To profess is an ethical
act,
and it makes the professional a
moral being, who prospectively affirms
also the moral nature of his activity."
(Leon Kass "Professing Ethically: On the

Place of Ethics in Defining Medicine" in the
Journal of the American Medical /Issoc/at/oz? March 1 1, 1983, p. 1306).

t,

All trades and human activities are ex
are
pected to be honest, industrious, reliable
and disposed to secure the good of persons.
But medicine has a special claim to be a

4

pro.ession since it touches the most basic
human values of life and health. Moreover
the pat.ent turns for help in matters that are

i

o.ten private, intimate and at times even
shameful. The patient is confronted with
his or her vulnerability and mortality and the
medical professional is called upon to help
in his or her struggle for survival or revival.
Human freedom and dignity are at stake.
The doctor or nurse should stand in awe
before the mystery of life and death, health
and sickness.
In spite of his drugs and
gadgets he or she is to be neither a proud
master nor servile technician. He or she is
at the service of the powers of healing
inherent in the human person or at the
mysterious passage from earthly life
to
eternal life.
Hence technology should not be the
dominating factor in the physician-patient
If should be entirely at the
relationship.
service of the process of integral healing. It
should never be used to unduly manipulate
the patient but should promote his freedom
and well-being. Thereby, the profession of
a ooctor or nurse becomes a true vocation.

Medical Service

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Medical Ethics Forum-35
By Fr. George Lobo, S.J.
Selling Organs for Transplantation
Case : An unempi oyed man with several
children offers to donate one of his kidneys
for a fairly big some of money. He also
donates his corneas to be taken after his
death for a recompense. Is such sale Heit?

3

With the discovery of a new anti-rejec
tion drug, cyclosporine, the incidence of
organ transplants and the corresponding
demand for organs is likely to rise. The
donor system in vogue till now does not
seem to provide the needed supply. To
meet the shortage. Dr. Barry Jacobs of the
U.S.A, has set up an International Kidney
Exchange Ltd., which would pay individuals
or families for organs.

t

There is no ethical objection to trans
plant.of corneas or other organs taken from
cadavars provided the respect due to the
dead human body is maintained and due
premission is obtained from next of kin
unless the person himself or herself had
donated the organ while still living. When
organ transplantation from living donors
was first introduced, there was reluctance
on the part of many ethicists to find this
procedure morally acceptable because it
involved mutilation or the loss of an organ,
e.g., kidney which is an integral part of the
body.- After some time, most ethicians con
ceded its acceptability provided the functio
nal integrity of the individual
was not
compromised. The donation of one of a pair
of healthy organs, such as the kidney would
be licit, as it did not in itself imply the loss
of functional integrity since the remaining
healthy organ could readily carry out the
required kidney function for the individual.

The risk to which the donor was placed by
the loss of one kidney if the remaining one
were later to become damaged by disease
or accident was considered acceptable ini
the light of the tremendous benefit to the
receiver who was joined to the donor by
charity or human solidarity. But would the
giving up of an organ be ever justified by
the motive of monetary compensation?
Those who oppose the payment system
hold on practical grounds that, as the experi
ence with blood transfusion shows, the
quality of organs with a price tag would go
down because the givier would be inclined
to hide a disease which if known would make
the organ unaccepatable for transplantation.
A volunteer donor would not likely be seri
ously tempted to hide such relevant
information. Besides, as some fear, this
would tend to make the poor a source of
spare parts for the rich which would be
against social justice.

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The main point s that organ donation
with the implied risk must be motivated by
suitably virtuous reasons which must be
proportionately serious. An organ donation
for the sake of money destined to be used
(Contd. Page 37)

&

31

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But would it be intrinsically evil to accept
financial recompense for an organ donated
for transplantation? Can one donate an
organ out of human solidarity and at the
same time accept money in exchange?
Many persons perform a work of charity or
minister to the sick and yet will accept a
salary. They would generally be willing to
work gratis if all the necessities of life were
otherwise provided. The salary need not be
the prime consideration.

September 1984

P

W-

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World Bank, the Population Council IPPF,
US AID etc. don't like children. Neither do
c drug firms. The pill is chemical warfare
against the women of the world".
Every morning the meeting started with
concelebrated Holy Mass and praying for the
needs of the various countries. On 15th
August, the day of, India's Independence,
Fr. John Vattamattom SVD of CHAI was the
main celebrant for the concelebrated Holy
Mass in the morning.
Fr. John in his
message requested the participants to pray
for India especially at this juncture when
respect for life is declining rapidly in spite of
the ancient rich religious heritage of the
country and the Principle of Ahimsa upheld
by its great leader Mahatma Gandhiji.
The final ceremony of the Third Inter
national PLAN Conference was a paraliturgy

wherein everyone in attendance
held a
lighted candle as each of the eight priests
in
present expressed,
succesion,
some
thoughts and prayers concerning right to
life. After each utterance, the group sang
the conference's "theme song," "The Light
of God," first in Spanish and then alternately
in English, French, and German.
The concluding message can be expressed
as follows : "You must light your own
candle. Overwhelming problems become
opportunities when you x____
trustx in God. The
real heroes of pro-life are the people in the
trenches.
Take time to read and learn.
Spread the message. Ail organizations exist
to serve people. Say lviva fa vida' once a
day. With Mary, let us always say 'Yes' to
the Lord’’, and therefore "Yes to Life".

dable for the donor to refuse recompense:
it is not necessarily a fault to accept it."
(Allocution to Eye Specialists,
May 14,
1956.)
Because of the current
climate of
dehumanizing dllllUUCO
attitudes towards
indiviluvvaiuo the uivtivi
dual person, it would be wiser to avoid the
outright selling of human organs. Of course,
suitable compensation for the cost of the
donor's surgery and possibly for the loss of
wages could always be demanded.
The
diminishing or risking one's physical integrity
for financial profit is to be avoided as far as
possible. But we could not outright con
demn a person who has recourse to it as a
last resort when he has to other way of
maintaining himself or his family. It is for
society to see that people are not driven to
such straights.

37

September 1984

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Uul I U 11 id i HZ! I: y

Years ago Pope Pius XII did 'not find
donation of corneas altogether illicit : "More
over, must one, as is often done refuse in
principle all compensation? This question
remains unanswered. It cannot be doubted
that grave abuses could occur if a payment
is demanded. But it would be going too
far to declare immoral every acceptance or
every demand of payment. The case is
similar to blood transfusions. It is commen-

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(Contd. from Page 31)
for obtaining luxury items would not consti
tute an adequate reason. But if the money
were to be used for basic necessities and
other funds were simply not available, then
the donation need not be viewed as morally
unacceptable. Of course, it is lamentable
that some people are in such straights that
they
have to resort to such extreme
measures to survive.

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—FR JOHN VATTAMATTOM SVD

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73
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Medicai Ethics Forum-34
Fr. George Lobo sj

a person who is impotent cannot perform.
So it is not sufficient for valid marriage that
the couple inteno to and are satisfied with
in complete sexual activity.

Impotence and Valid marriage
Case :
A girl know that her prospective partner
is impotent. She is ready to accept a union
without complete sexual act and without
children. Can they enter into a valid mar
riage?

The above argument is from the nature
of marriage and its specific activity. But
even from a practical point of view the
marriage of a girl with a certainly impotent
man in far from being advisable. Apart from
the difficulty arising from want of children,
a life long abstinence when it is not called
forth from a rare spiritual motive or mutual
sexual stimulation without the possibility of
normal satisfaction would put too great a
strain on the relationship.

In the past when procreation was gene
ra ly regarded as the primary end of marriage,
it was evident that one who was impotent
could not validly marry. Now as the stress is
on partnership and love, many are wondering
whether impotence (Or inability to perform
normal and complete marital act should be
considered as a total barrier to marriage).

I^3
M

O■ ■W
ji£

j

Anyway the Church is categorical about
excluding marriage of an impotent person.
If there is a doubt about the condition, the
Church would permit the marriage to take
place (Can. 1084,2). If later the impotence
becomes certain, the Church would grant an
annualment with the possibility of the other
partner entering into another union or grant
a dissolution of the bond on the ground of
non-consumrhation. Even when the im
potence is doubtful, the girl should be
coutious about entering into the union lest
she may have to suffer a lot of frustration.

However, Canon Law is very clear on the
matter : "Antecedent and perpetual im
potence to have sexual intercourse, whether
on the part of the man or on that of the
woman, whether absolute or relative, by its
very nature invalidates a marriage." (Can.
1084. 1).
This is because marriage is "partnership
of the whole of life" which evidently includes
the capacity to perform the marital act.
Partial sexual stimulation by its nature is
ordained to complete sexual activity which

??

3

April 1984

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Medical Ethics Forum-34

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Fr. George Lobo sj

•I
Impotence and Valid marriage
Case :
A girl know that her prospective partner
is impotent. She is ready to accept a union
without complete sexual act and without
children. Can they enter into a valid mar
riage?
In the past when procreation was generaly regarded as the primary end of marriage,
it was evident that one who was impotent
could not validly marry. Now as the stress is
on partnership and love, many are wondering
whether impotence (Or inability to perform
normal and complete marital act should be
considered as a total barrier to marriage).
However, Canon Law is very clear on the
matter : "Antecedent and perpetual im
potence to have sexual intercourse, whether
on the part of the man or on that of the
woman, whether absolute or relative, by its
very nature invalidates a marriage." (Can.
1084. 1).

I

I

This is because marriage is "partnership
of the whole of life" which evidently includes
the capacity to perform the marital act.
Partial sexual stimulation by its nature is
ordained to complete sexual activity which

I

T ■

a person who is impotent cannot perform.
So it is not sufficient for valid marriage that
the couple intena to and are satisfied with
in complete sexual activity.
The above argument is from the nature
of marriage and its specific activity. But
even from a practical point of view the
marriage of a girl with a certainly impotent
man in far from being advisable. Apart from
the difficulty arising from want of children,
a life long abstinence when it is not called
forth from a rare spiritual motive or mutual
sexual stimulation without the possibility of
normal satisfaction would put too great a
strain on the relationship.
Anyway the Church is categorical about
excluding marriage of an impotent person.
If there is a doubt about the condition, the
Church would permit the marriage to take
place (Can. 1084,2). If later the impotence
becomes certain, the Church would grant an
annualment with the possibility of the other
partner entering into another union or grant
a dissolution of the bond on the ground of
non-consummation. Even when the im
potence is doubtful, the girl should be
coutious about entering into the union lest
she may have to suffer a lot of frustration.

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April 1984

35

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Medical Ethics Forum—32
Fr. George V. Lobo S.J.
Concea' ng the Truth

reveal a fact known to someone, and at times
one must not do so.

Case :—A devoted husband in a moment
of weakness is unfaithful to his wife for one
and only time. Sometime later, he realizes
that he has contracted venereal disease, and,
thoroughly repentant, presents himself for
treatment to his family physician. He asks
the physician, when his wife comes for a
routine check-up, to conceal from her any
diagnosis of venereal disease, should she
have contracted it. The man fears for his
marriage and her feelings.

The right of the other to know is condi
tioned by his or her reasonably implied will.
A maturely perspicacious wife would nof
reasonably expect that the family physician
would give her information (1) which it is
strictly not necessary to treat a mysterious
vaginal infection ; (2) which the doctor is
convinced would inflict useless mental
anguish on her ; (3) which would needlessly
humiliate a repentant and anxious husband ;
and (4) which would severely strain their
marital relationship.

Truth is a prime human value. Honesty
in communication is a must for mutual trust.
This is particularly so in the case of the
doctor-patient relationship. However, speak
ing the truth does not always mean giving
out all the facts that one has in one's mind.
One is obliged to reveal what the other has
the right to know. Otherwise, one need not

Under the circumstances, then, the doctor
could use human language effectively to
conceal the fact. Any artifice required is
generally called a 'mental restriction*. But
as it falls short of the ideal of transparency
in human communication, it should be used
sparingly and only to the extent necessary to
safeguard other grave human values.

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i
I

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36

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Medical Service

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Medical Ethics Forum-31

iI

Kw ■

While the whole Code touches the life of
every Christian .in some way, some laws
affect medical personnel in a special way.
The new Code stresses the common obliga
tions and rights of all the members of the
Church. "All the faithful who are reborn in
Christ are equal in dignity and action which
each one according to one's proper condition
and role, contributes to the building up of the
Body of Christ." (Can. 208)
Role of the Laity

1

i

The laity are especially called to imbue
the temporal order with the spirit of the
Gospel (Can. 225,5). Hence the healing
activity of Christian doctors and nurses is to
be inspired by the saving and healing mission
of Christ.
The due freedom of the laity in temporal
matters is to be recognized, although they
have to be attentive to the teaching of the
Magisterium (Can. 227).
Those who are
eminent in competence and prudence could
be called to be experts and counsellors to
the pastors of the Church (Can. 228,2.)
They have the duty and the right to acquire
sufficient knowledge of Christian doctrine
(Can. 229,1). This is all the more necessary
when they gain expertise in medical know
ledge and skills.
Right of Association

i

The faithful may form associations for
fostering Christian life or the apostolate
March 1983

,W.

II®:-

Fr. George Lobo, S.J.

The New Latin Code of Canon Law and
the Medical Practitioner introduction

II

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K-

(Can. 298,1). This applies to Doctors' and
Nurses' Guilds. No association is to call
itself Christian without the consent of com
petent ecclesiastical authority (Can. 300).
All such associations are subject to the vigi
lance of ecclesiastical authority in order to
preserve integrity of faith and morals
(Can. 305,1).
Sacraments in General
In case of necessity or real spiritual good,
provided there is no danger of error or indifferentism. Catholics may receive the sacra
ments of Reconciliation, Eucharist and Anoin
ting from a non-Catholic minister of a Church
in which these sacraments are truly found if
it is physically or morally impossible to
approach a Catholic minister (Can. 844,2).
In India this applies particularly to the Syrian
Orthodox Church. The need may particularly
arise when there is danger of death.
Catholic ministers may minister the same
sacraments to non-Catholic Orientals if they
ask of their own accord and are rightly
disposed (Can. 844,3). In danger of death,
or other need, according to the judgement of
the bishops, these sacraments may be given
to other non-Catholic Christians if they cannot
approach their own ministers, ask of their
own accord, have the Christian faith regarding
them and are rightly disposed (Can. 844,4).
In the administration of the sacraments,
the oil used should be from olives or other
plants. They have to be blessed by the
bishop (Can. 847,1). although the oil for
anointing, in thejcase of necessity, can be
25

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blessed by any priest during the celebration
(Can. 999,2).
Baptism
Baptism is not to be celebrated in a hos
pital unless the bishop decides otherwise, or
in case of necessity or other important pas
toral reason (Can. 860,2).
In danger of death, the infants of Catholic
or non-Catholic parents are licitly baptized,
even
the
parents
are
unwilling
if
(Can. 868,2).

■!

An exposed infant or foundling is to be
baptized unless it is clear after diligent inves
tigation that Baptism has already been con
ferred (Can. 870). If it is thought prudent
to give the infant be adopted by non- Catholic
parents, Baptism would not be advisable.

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An aborted foetus, if alive, is to be bapti
zed as far as possible (Can. 871). There
is no reference in the new law to intra-uterine
Baptism.

■■

va

Confirmation

'I

In the danger of death, the parish priest,
and indeed any priest can minister the sacra
ment (Can. 883,3°). It can be given to
children of any age in danger of death.

Ma

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i

Euachrist

1

Small children in danger of death may be
given H. Communion if they are able to
discern the Body of Christ from common
food and receive it reverently (Can. 913,1,).

I
r'

One must abstain from food and drink,
except water and medicine for an hour before
receiving H. Communion (Can. 919,1). The
elderly and the sick as well as those caring
for them may receive the Eucharist even if
they have taken something within the hour
(Can. 919,3). Hence medical personnel on
duty are not strictly bound by the eucharistic
fast.

>

•1

1

The faithful who are in danger of death
from any cause are to be refreshed by
H. Communion or Viaticum (Can. 921,1). If
they are in a critical condition, even though
they have already received Communion that
day, it is highly recommended that they
communicate again (Can. 921,2). If the
danger of death continues, it should be
administered several times on different days
(Can. 921,3). The Sacred Viaticum is not to
be delayed too long. Care must be taken
to receive
it
in
full ’ consciousness
(Can. 922).
A sick or elderly priest, if he is not able
to stand, may celebrate sitting down, not
however before the people without the
permission of the local Ordinary (Can.
930,1).
A blind or otherwise sick priest may
licitly celebrate Mass using any of the
approved texts, with the assistance, however,
of another priest, deacon or even a properly
instructed lay person (Can. 930,2).

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In case of need. Mass may be celebrated
in any decent place (Can. 932,2), in which
case there must be a convenient table, and
always a table cloth and corporal (Gan.
932,2).
Reconciliation
A priest who has habitual faculties for
hearing confessions, by virtue of an office or
concession of the local Ordinary, can exercise
the same anywhere in the world unless the
Ordinary of the place forbids it (Can. 967,3).
In the danger of death any priest can
validly and licitly absolve any penitent from
any censuries and sins, even if an approved
priest is present (Can-976).
Anointing of the Sick
Pastors and relatives should see that the
sick receive the sacrament in due time
Medical Service

26

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f22-71

er of death
reshed by
921,1). IT
en though
nunion that
that they
2). If the
should be
ferent days
jm is not to
ist be taken
nsciousness

(Can. 1001). It may be ministered to a
faithful "who having reached the use of
reason, begins to be in the danger of death
due to sickness or old age" (Can. 1004,1)..
It may be repeated if the sick person, after
rallying, again fails into grave sickness, or if
in the same sickness, the danger becomes
graver (Can. 1004,2). In doubt about the
use of reason or the gravity of the illness,
the
sacrament
is
to
be
ministered
(Can. 1003). Hence the sacrament must be
understood more as that of the sick than of
the dying.

r

a is not able
down, not
without the
inary (Can.

The sactament may be conferred to a
sick person who at least implicitly asked for
it when he
or
she
was
conscious
(Can. 1006). It is not to be given to one
who obstinately perseveres in grave sin
(Can-1007).

priest may
any of the
ce, however,
a properly

Marriage
The New Code emphasizes the need for
proper preparations for marriage (Can. 1063).
Doctors and nurses may be called upon to
play an important role in this.

2).
3 celebrated
2), in which
nt table, and
Drporal (Can.

faculties for
an office or
, can exercise
rid unless the
Can. 967,3).
ny priest can
Denitent from
f an approved

see that the
in due time

edical Service

!

Now an 'human act' is required for the
consummation of marriage (Can. 1061,1).
Hence sexual intercourse by a drunken hus
band or one that is. violently imposed would
not consummate marriage and maka it
absolutely indissoluble (Can. 1141).
Marriage impediments have been greatly
simplified. For instance, only relationship up
till that of first cousins in the collateral line
invalidates marriage (Can-1091). There is
no more any impediment of affinity in the
collateral line (Can. 1092).
Impotence (inability to perform coitus)
that is antecedent and perpetual invalidates
marriage
(Can-1084,1). According to a
decree of the S. Congregation for the Do
ctrine of the Faith, 13 May 1977, it is clear
that double vasectomy as such does not
constitute impotence. One may likewise
March 1983

conclude that women who have undergone
tubectomy, those with retroflexed uterus
or even those lacking postvaginal organs are
not to be excluded from marriage. It seems
also probable that even one with an artificial
vagina that is functional could validly marry.
Sterility neither prohibits nor invalidates
marriage (Can. 1084,3), unless it ip purposely
concealed (cf. Can. 1098). Error regarding
fertility as such does not invalidate marriage
unless the quality is 'directly and principally
intended* (Can. 1097,2). It may happen
that some persons, especially because of a
particular cultural background, may so desire
fertility in the partner that in its absence
marriage would not only be difficult but
absolutely inconceivable. In such a case an
error regarding the quality of fertility may
amount to error regarding the person and
thus invalidate marriage.
The expertise of psychiatrists would be
called in especially in evaluating the psychic
factors that would substantially vitiate the
marriage consent : 1) lack of sufficient use
of reason; 2) grave defect of judgemental
discretion concerning the essential rights and
duties of marriage to be mutually given and
accepted; 3) psychic causes that make a
person incapable of assuming the essential
obligations of marriage (Can. 1095). An
example of the last would be true homo
sexuality.
Children who are born at least 180 days
from the day of marriage or within 300 days
of the dissolution of marriage are presumed
legitimate (Can. 1138).
Funerals
The Church still strongly recommends the
pious custom of burial, but does not forbid
cremation unless it is chosen for reasons
contrary to Christian doctrine (Can. 1176,3).

27

Penalties

Apart from notorious apostates, heretics
and schismatics, as well as those who have
chosen cremation for reasons contrary to the
Christian faith, ecclesiastical funeral is to be
denied only to other manifest sinners to
whom it could not be granted without public
scandal of the faithful (Can. 1184). Regar
ding suicides, we may doubt in most cases
about the existence of manifest subjective
guilt or the scandal could be averted through

c

Those who commit homicide or grave
mutilation are to be punished with various
expiatory penalties (Can. 1391,1).
Those who effectively procure abortion
incur ipso facto excommunication (Can.
1398,2). The penalty, however, presumes
that
deliberation and grave subjective
imputability
are
present
(Can. 1323

A Study
Leprosy for c
at Geneva fre

and 1321).

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28

Medical service

(i) the
health perse
cases on cor

i

March 198C

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Role of the Ministry of Healing—A Perspective

W

—Dr. George Joseph

During the past few decades, nations of
the world particularly those that have won
political freedom and are free to guide the
destinies of their people are engaged in an
all out effort to improve the quality of life of
people by pursuing strategies of development
akin to their ideologies. The socio-political
upheaval, meant to liberate man from all that
'cabins, cribes and confines him' has led to
increase his longing and aspiration for a
better life. Technological break-throughs
and speedy advances in the Communication
media have had their inevitable contribution
to make.

I

In India, during the post-independence
era major efforts were made to provide basic
health care to its people particularly those
spread over the 6,00,000 villages. The entire
rural India was divided into Community
Development Blocks accommodating, appro
ximately, 100 villages per Block for integrat
ed development and a primary health centre
allocated to each of them for providing inte
grated health services. We have today over
-5,400 PHCs engaged in this effort. In spite
of the substantial investments made, the
health status of our people today is far from
satisfactory. No doubt, we have made im
pressive achievements in many crucial areas
particularly in the areas of control of commu
nicable and pestilential diseases and Family
Welfare Planning. The sheer magnitude of
the task that still remain is so great that one
almost despairs of meeting our health needs
or realising our aspirations on the basis of
the broad models of health care, we seemed
to have accepted. *An alternate strategy of
development of health care services was

therefore evolved which marked a major
departure, based on the following principles.
— A universal and egalitarian programme
of efficient and effective health ser
vices cannot be developed against the
background of
socio-economic
a
structure in which largest masses of
people still live below the poverty
line. Therefore there should be sus
tained and vigorous attack on the
problem of mass poverty and for crea
tion of a more egalitarian society.
— Development essentially means the
development of man and not of things:
Emphasis should be on the develop
ment of human rather than the material
resources. The most significant tools
for the purpose are education and
health. Taken together they form the
most powerful instruments for the
development of man and human re
sources.

vices from the industrially advanced
and consumption oriented societies of
the west has inherent fallacies. Health
gets wrongly defined in terms of
consumption of specific goods and
services, basic values in life which
essentially determine its quality gets
distorted; over-professionalisation in
creases costs and ultimately has an
adverse effect even on the health and
happiness of people. We have to take
a conscious and deliberate decision to
abandon this model and strive to

August 1984

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— Adoption of the model of health serJ

Report of the Group on Medical education and support man power—Government of India, April
1975.

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create instead, a viable and economic
alternative suited to our conditions—
the new model will have to place
greater emphasis on human effort
rather than on monetary inputs.
— Health is essentially an individual
responsibility in the sense that, if the
individual cannot be trained to take
proper care of his health, no Commu^,
nity or State programme of health
services can keep him healthy. The
issue is basically one of education.

I

— The community has the great respon
sibility in the sense that, if the indivi
dual cannot be trained to take proper
care of his health, no Community or
State programme of health services
can keep him healthy. The issue is
basically one of education.

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— The community has the great respon
sibility to provide a proper environment
for helping each individual to be
health—supply of safe water—ade
quate measures for disposal of human
excreta and the like. These social
aspects of health need strengthening
and the highest emphasis.

- •
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— The over emphasis on the provision of
health services through professional
staff under state control has been
counter productive. It devalues and
destroys the old tradition of part-time
semi-professional workers which the
community used to train and throw up
and which with certain modification
will have to continue to provide the

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fou ndation for the development of a
national programme of development in
our country. We have to have large
bands of semi-professional workers
from among the community who
would be close to the people live with
them and provide medical services.
This bold Indian experiment roused the
attention of planners and administrators all
over the world, In fact, there was great
concern expressed by the International
Community of experts who came forward to
assist the third world countries in evolving a
health care strategy to’ match the health
needs of communities particularly, those who
have long been denied the benefits of even
elementary health care. The Alma-ata decla
ration (1978) by the WHO has emerged out
of this concern. The concept of Primary
Health Care* gives a positive direction to
planners and administrators in this regard
and even provides operational guidelines.
i

Government of India came out with the
National Health Policy in 1982, which by and
large is dictated by the emerging world
opinion about the need to evolve a health
care strategy to match the needs. The task
that we are addressing ourselves today is
the building up of a multi-tier health establ
ishment that has its very roots in the ruial
homes. Administratively, the peripheral most
unit is the village level family health and
welfare centre and whence the services
trickle down further through the agency of
the village volunteers who help carry the
message of health to the rural homes. The
peripheral units are backed by a referral
system that provides for the upward and

L
Primary Health Care is essential health care made universally accessible to individuals and families
in the community by means acceptable to them and at a cost that the community and country, can
afford. World Health Organisation, Primary Health Care, WHO, Geneva, 1978.

6

Medical Service

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downward flow of services. The PHC's the
Taluk and District hospitals and the institu
tions that make provision for specially and
super speciality services at the apex, are all
linked together in a bid to provide regionalised health care services, each link in the
chain, meant to provide clinical care at a
given level of expertise.

a
in
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ers
ho
ith
he
all
sat
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to
3 a
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ho
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to
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Admittedly, the building up of a health
care hierarchy of such magnitude
need
The
stupendous efforts and
resources.
growing importance of the voluntary sector
in supplementing the national efforts is at
once obvious. It is against this background
that one has to look at the present day
activities of our institutions under the Minis
try of Healing
How do they conform to the
goals as laid down by the national' health
policy ? The foremost task ahead of the
Ministry today is to assist in this effort to
bring primary health care within the effective
reach of people. The present day health
care institutions under the church namely our
hospitals—are required to provide the leader
ship in operationalising the programme of
extending primary health care to communi
ties. With the courage of conviction, let me
state that the church and its Healing Ministry
has hitherto faced no greater challenge at
any time.
It may be recalled that our hospitals, re
present pioneering efforts on the part of
dedicated medical missionaries mostly from
abroad to provide the much needed medical
relief and succour to large segments of
humanity at a time when health efforts by
governmental agencies in the various states
were barely rudimentary. Suffice to say that
our institutions had a decisive and historic
role to play as forerunners of the present day
health establishments in the different states,
particularly in terms of quality, content and
coverage of health care.
August 1984

We have today as per information avail
able from the Synod Secretarial, 69 hospitals
and 111 out-reach clinics in the 4 regions of
the Synod. Now let us come to the crucial
question about the role of our institutions
under the Healing Ministry as an extended
activity of the church. Time has come when
one has to critically look at their present day
activities and style of functioning and their
relevance in today's national context—more
than that, their role as an extended activity
of the church. Do we need to sustain and
perpetuate them purely for historical reasons
or do we envisage a new role for them as
powerful 'agents of change' in the context of
development?

tl.

II

I have attempted in the presentation so
far to highlight the scope and relevance of
not only continuing the activities of our hos
pitals but also the great role they are expect
ed to play in the context of the present-day
national efforts to implement primary health
care. What is needed today is to bring about
a different orientation in our thinking to en
able us in our future planning. Can we not
offer leadership at this crucial phase? This
calls for, among other things, a realignment
of our priorities.
Representatives of 21 dioceses have met
and discussed the futuristic role of the exist
ing institutions and have reached a consen
sus that the greatest challenge that faces us
today is to assist in the national endeavour
of extending primary health care to the rural
population.
Plans have been drawn to
develop models of health delivery systems
suitable in the various social and cultural con
texts. The general pattern that has emerged
is to bring under the purview of the existing
rural hospitals the responsibilities of extend
ing basic health services to communities in
The operational
their catchment areas.
mechanism suggested is the development of
satellite centres manned by basic health

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workers. The activities of the satellite centres
will be supplemented by the activities of the
village level workers selected and trained by
the local health team. With this the role and
style ot functioning of the hospitals will be
greatly altered. They will no longer wait for
patients to come to them but reach out to
the periphery, identify the needs and assume
responsibility of supervising the health of
people in the rural homes.

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suitable to the needs of people, relevant and
feasible in the social context, under the aegis
of the existing institutions namely, the rural
hospital. In the 21 dioceses the needs vary
vastly. There are dioceses where even sembolance of a health system does not exist.
We are called upon to extend care to those
who are denied these all their lives, imbued
with a spirit of dedication and upholding
Christian ideals.

Adoption of this new role to foster the >
The concept of primary health care, is in
development of health of communities marks
essence inspired by the loftiest Christian
a major departure from the traditional one.
ideals which our Lord Himself demonstrated
during his earthly life and mission, namely
The success of such an attempt will depend
on the dedicated endeavour of the health .'reaching out' for the lowliest and lost. Let
me refer to one such instance, the healing of
team. Development of health man power,
the impotent man at the pool of Bethesda
therefore, is almost a pre-requisite to the
who bore his infirmity for 38 years, most of
success of such programmes. Our dioceses
which probably he spent at the pool of
are concerned about this need for developing
Bethesda next to the sheep gate. He passes
appropriate health man power. The existing
before us nameless and seen as one among
training institutions which hitherto were res
the crowd, John's description of that crowd
ponsible for turning out personnel for institu
is graphic. He says that in the porches lay
tionalised services have now to employ their
a multitude of sick, blind, halt, withered.
training resources for preparing the required
Here, we see a company of the unfit, the
man power representing competence at
the outcaste, all probably waiting,
derelict,
different levels. Dioceses where such facili
desiring
a cure. Christ that day chose to go
ties do not exist will have to develop training
that
way
to meet the impotent man. It is
capabilities or utilise available facilities of
said,
that
it
is not his usual way to go to
sister dioceses preferably of the same socio
Jerusalem.
Going out to meet the people in
cultural background. This pooling and shar
need
is
therefore
our Christian goal, carrying
ing of resources should become an accepted
the
message
of
love
and hope. Our job then
norm between institutions within the dioce
is to develop a model of health care in a
ses or between dioceses not only confined
given context so that others can emulate that
to this area of training but even to the service
example. It is the job of lighting a lamp and
programmes.
keeping it on a pedestal.
Responsibility of evolving/developing
'models'
I for one, an convinced and I am sure
there are many here who share the same
conviction that the task ahead of us today is
to evolve and develop 'models' be it in rela
tion to health, education dr development.
Can we help evolve models of health care

8

Apart from the prime task of assisting in
the process of extending primary health care
especially among the socio-economically dis
advantaged groups, there are some other
vital issues that deserve consideration of the
Healing Ministry as a matter of policy.
— identification of newly emerging com
munity health problems brought about
Medical Service

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by rapid changes that are occuring
both in the demographic and socio
economic seenes and evolving models
of care feasible within the frame of
reference of the church and the heal
ing ministry.
For example the care of the aging and the
aged. The problem is vast and complex with
serious social implications.
However the
gravity of the problem has not been appreci
ated even today. It is timely and opportune
for the ministry of healing to evolve feasible
models of care relevant in the given social
context.

9
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— evolving patterns of care for vulnerable
groups in our society as part of health
related social welfare programmes.

if

For example day care centres creches,
nurseries for children of working women.
This is visualised as part of comprehen
sive family welfare scheme especially
among labour populations such as planta
tion workers, fishermen in the coastal
, areas, agricultural labourers, tribal popula
tion etc., where women go for work
ordinarily or can seek gainful employment
at least during seasons.

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Health and welfare programme for the
disabled.

g
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t
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This should be viewed as a very challehgmg task ahead of the church and the ministry
of healing. A comprehensive programme
should include not only assessment of the
nature and the extent of the problem in a
given area. Say, under the jurisdiction of
the local churches and the comunities direct
ly under its influence, put also the identification of local r~
resources. training of local
leadership as well
«.! as local volunteers who
could help in a comprehensive rehabilitation
programme. The ministry should' visualise
service for the disabled including their reha-

3

August 1984

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— Comprehensive health programmes for
the control of diseases like leprosy,
tuberculosis.

2:

Activities of the ministry of healing should
lay continued emphasis on programmes for
the control of diseases like, leprosy, tuber
culosis especially those which have a social
dimension. However, one has to strike a note
of caution in that such efforts should fit into
the national strategies for the control or era
dication of such diseases. Any such pro
gramme should make adequate provision for
the rehabilitation of the individual as well as
the family.
Quality
church

of care-chal'enge

before

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the

I shall confine myself to two aspects of
this question which are of immediate rele
vance to our ministry.
Here, quality, refers to
'acceptable'
standards of care—and even so, is very diffi
cult to define, as it is highly variable accord
ing to the, context in which it is used. There
is a growing tendency among the lay public as
well as the profession to always equate equa
lity with enhanced cost of services. Services
given at a low cost are branded as 'second
quality and substandard. This has serious
implications in the field of health services. It
even helps to demoralise the personnel who
provides such services. Let us accept that
'quality of care' refers to what is best for the
person, and is feasible to be administered in
a given context and which is scientifically
sound. A family health worker who advises
a village mother, to compound a home

9

,

I

biiitation as part of the total health responsi
bility to the community. Planning of such a
programme would, inter alia, include the
training of the required personnel for under
taking comprehensive
rehabilitation pro
gramme at the regional centres.

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remedy to rehydrate her child ailing from
vomiting and diarrhoea, from the commonest
of household provisions readily available to
her (salt and sugar) is practising high quality
scientific medicine. In fact she is practising
better scientific medicine than the private
practitioner who prescribes a combination of
antibiotics and other drugs with brand names,
--the bane of over-professionalisation and
high technology.
The second aspect is of equal
greater relevance to our ministry.

if not

it is a common experience that in our
quest to provide quality of care of our
patients, to make our institutional services
acceptable to public at large, we often tend
to lose sight of our Christian calling and
ideals. Let me illustrate : for e.g.—the service

card. We know the instance when he didn't
have enough to pay the temple tax. I am
afraid, as per rules of the establishment he
will be sent to a dingy ward.
4

Now, let us look at the resource—impli
cations. if we consider the general ward
patients especially the non-paying ones as
our guests of honour, guests of the church
and of the diocese, these problems can easily
be resolved. Then it becomes incumbent on
the church and the parishioners to welcome
them, to treat them, to feed them and take
care of them demonstrating the tender loving
care of Christ and meet the cost thereof.

10
Medical Service

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Mother Teresa has said that she tries to
see the face of infant Jesus in every child
picked from the street, from under the
we extend to our patients in the general
garbage or from the gutters. We in the
ward and the non-paying ones—the apparent
ministry have to be guided by nothing less
discrimination shown in the quality of care.
than this standard of Christian service. The
Often resource contraints are blamed. It is
responsibility should be basically that of the
a common experience that we deny even
whole church as it should serve as a living
basic amenities to these persons. We try to
example to demonstrate Christian love in
save on ceiling fans and even mattresses and
action. This, then is the present day challenge
pillows on the plea that these are luxuries to
before our institutional ministry and let us
which these people are not accustomed to.
look forward to an era of dedicated endeav
In such matters there can be only one
our on the part of our institutions to reach
standard to be set as a guide before us—
out to even the remotest needy villages in
namely, what would Christ want us to do?
our dioceses with the message of 'health' ■
Thus as a matter of very great concern
I
inspired by the Love of Christ and to be
often feel that if Jesus Christ were to seek
qualified to receive his commendation on the
admission in one of our hospitals, of nece
final day of judgement 'Come and posses the
ssity, will have to be a general ward patient
kingdom which has been prepared for you
and that too, a non-paying one. If he
ever since the creation of the world. I was
happens to walk in alone into a casualty
hungry and you fed me, thirsty and you gave
department, exhausted after a long day's toil,
me a drink, I was a stranger and you received
with bruises on his feet due to the long walk
me in your homes, naked and you clothed
through the rugged country side, what would
me, I was sick and you took care of me, in
be the type of welcome we extend to him?
prison and you visited me. Whenever you
Of course, he wouldn't have enough to pay
did this for one of the least important of
the caution deposit or even to buy the O.P.
these brothers of mine, you did it for me.'

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1

HIV, LAW AND ETHICS
Introduction
What are the human rights, laws and ethics in the Human Immuno
Syndeficiency Virus infection and Acquired Immu no-deficiency
debate
drome epidemic?
Many policy responses are shaped by the
about public hea1th versus individua1 rights;, the need to uphold
the rights of individuals and the need to protect others and
society in general. The ongoing reports of serious and unjusti
fied encroachments on the civil liberties of people with Human
Immuno—deficiency virus have established beyond doubt that the
laws have an important role to play in HIV / AIDS policy,
So
also,
there is need for guidelines on the ethical conduct of’
health professionals and health care institutions.
What should the legal
leqal response be? Can legislation assist in
strategies for the care and treatment of people with HIV arhd help
to reduce the spread of HIV? What has been the experience in
legal remedies for HI£ AIDS re 1 ated discrimination?
seeking
Are legal sanctions ever helpful in bringing about the changes
that will be necessary to respond effectively and approprixately
to HIV / AIDS?
What should the ethical response of the health professionals
and
health care institutions be to this pandemic, which threatens our
coun try?

THE STORY OF DOMINIC D'SOUZA
At 8 am on 14th February 1939, Dominic D'Souza living in Goa was
asked to report to the police station.
On arrival, he was taken
He was told that ne must
to the local hospital by two policemen,
undergo a physical examination, Six policemen were standing at
the door of the casualty ward. two of them armed with rifles.
The examining doctor entered Dominic s name in a register.
On
This was how
the cover of the book was written the word "AIDS".
Dominic first came to know that he was infected with the human
immunodeficiency virus (HIV).
There was no explanati □n, no
counse11inq•
From the hospital, Dominic was taken by the police to a •former TB
sanatorium where he was to be detained against his will indefia i one,
nitely.
He was placed in a small dirty room, completely
to
not knowing what would happen to him. He was not permitted
contact his family or friends to let them know where he was.
Over
the next few days. the reason for his detention became
The
clear.
months previously
He had donated blood severa1
hospi ta1
had tested his blood for HIV without his knowledge or
consent.
The Hospita1
It was found that he was HIV positive.
2

1

/

informed the police.
The oolice had then acted in reliance Of »
the Goa Public Health Act which provided for the mandatory deten
tion of all HIV positive persons. Under the Act detention was
indefinite,
regardless of whether there was any actual
risk of
HIV transmission to other members of the public.
His family and friends
Dominic continued to remain in detention.
made representations on his behalf to the government pointing out
the injustice of his detention.
He received extraordinary support from the people living in his village. They wrote demanding
his release. Eventually he filed a court case challenging the
validity of the legislation authorising his detention.
After 64
days of detention, Dominic was granted interim leave to return
home ...... not because of any illegality in the detention provi
sions as such, but only because the court considered that the HIV
testing procedure that had been followed was not sufficiently
reliable to justify detention.

Legal and ethical issues arose at every point in Dominic s story.
His blood was tested for HIV without his consent.
The hospital
.—>
did not disclose his HIV status to him.
Confidentiality was
breached by reason of the disclosure to the police.
He was
detained under the Public Health Legislation.
For Dominic, the story did not end there,
When he attempted
to
return to work, he found that his job had already been given to
someone else. His employer asked him to resign because of concern
that other employees would not want to work with a ber son
with HIV.
A RECENT STORY

If the story of Dominic is history, here is a recent incidentPremsingh Kanchan Singh Gujjar, a milk merchant, was admitted
to
Rajasthan Hospital on November 26, 1994.
He underwent the surgical
During the operation, the report
removal of his left lung,
lung.
came that his blood tested HIV positive.
He was bundled out of
the hospital within 12 hours of surgery.
Reason given by the
Medical
Superintendent : "Private hospitals have to be careful
about their reputation. Cur staff would have objected to treatinq an HIV positive patient". No one attended on the patient,
Premsingh said:
"That night was a nightmarish experience.
No
nurse or attendant came to check. The watchman peered from the
door* and the staff kept on whispering that nobody should approach
me" .

2

HUMAN RIGHTS AND HIV
Two ooints arise when discussing human rights with respect to HIV
epidemic.

Point one:

the
Many of the people who have been and will be affected by
The
epidemic are the socially and economically disadvantaged.
burden of HIV infection will be borne more and more in the years
to come by people in the poorer countries.
In these countries,
infection rates are increasing disproportionately among the poor
women.
The socio-economic vulnerabi1ity to HIV infection
operates in
People who have access
many ways. HIV infection is preventable.
to information and preventive measures and have the means to
implement them can protect themselves against infection,
The
people who remain vulnerable are those who do not have the means
to protect themselves or are powerless to control the basis of
their sexual re1ationships. Many factors decide these:
poverty,
geographical isolation., inadequate health education and cu1tura1
values.

Point two:
HIV policy debate centres around the conflict between plublic
interest and individual rights. Policies infringe individual
rights, such as mandatory HIV testing and detention are justified
on
the basis of a need to protect the health of the people.
However, an effective response to HIV infection requires a recog
nition by all (infected and uninfected) and by communities and
governments that they have a common interest in working together
to contain the spread of HIV.
Alienating people with HIV, making them feel
that they have
nothing to gain by protecting themselves or others can work
counter to measures to contain spread of infection. Policiejs and
laws which reduce the stigma attached to HIV infection and
bui Id
self-esteem are likely to create an environment of mutual
trust,
support and collaboration. This can bring about the sustaining
behaviour c hange.
HIV and the LAW

It is useful to analyse the various models by which the law can
be incorporated into HIV / AIDS policy. Three main models a rise .
The first is the traditional proscriptive model
that penalises
forms of conduct. The second model focuses on the procertain
tective function of the law and the need to uphold the rights and
with
interests of particular classes of people, those infected
HIV or at risk of infection.
The third is the instrumental
3

It seeks to use the law actively to promote the changes
model.
in values and patterns of social interaction that lead to sijsceptibility to HIV infection.
The proscriptive role of the law

The impact of the law in its proscriptive mode on HIV / AIDS
policy became apparent very early in the epidemic because of the
particular epidemiology of HIV. The two groups most affected by
HIV in the West - homosexual men and injecting drug users - were
people whose sexual or drug-using activities were not acceptable
to the society in general and was considered as criminal offence,
Che response to the activities that were placing people at risk
lega 1
of HIV infection had to be formulated in the context of
prohibitions on these activities.
The involvement of the law in HIV / AIDS policy in this way often
obstructed rather than facilitated effective policy impleijnen ta
These are the laws, for example, that have led workers in
tion.
needle-exchange programmes to fear they may be prosecuted for
the
aiding and abetting an illegal activity or for possessing
traces of illegal drugs that remain in used needles and syringes.
They have caused those people who are most at risk of HIV infection to
te be reluctant to identify themselves as being at ris k for
fear of adverse legal consequences.
The enactment of proscriptive laws directed specifically at IHIV /
AIDS has been counterproductive.
counterproductive. Examples: 1)
laws for the
laws which
compulsory reporting of HIV seropositivity:
(2)
seropositivity:
require HIV testing of certain population groups.,
groups, such as i mm i grants;
(3) laws that compel the disclosure of an
individual's
The coercive nature of
HIV status in certain circumstances.
these laws, which often impose criminal
sanctions for inori
They alienate
compliance may actively impede prevention efforts,
those people who are at risk of HIV. It is less likely that they
will co-operate in prevention measures.
The protective role of law

A second model in HIV / AIDS policy focuses upon how the law can
an ci
protect individuals or classes of individuals from harmfi 1
undesirable occurrences.
This model has been of importar ce in
the context of the legal response of HIV / AIDS because df the
proliferation of discrimination against people with HIV and
between
because of the increasing recognition of the interplay
AIDS and human rights. Accordingly., legal instruments such as
human rights and antidiscrimination legislation that embody the
and
protective role of the law have been proposed as practical
assist
policy.
law
can
HIV
/
AIDS
effective ways in which the
to be
Laws that protect individual rights and interests must.,
incorporate a proscriptive element that imposes cereffective,
the
But the objective of
tain penalties for non-complaince.
4

legislation is positive rather than negative; to engender respect
for individuals and to promote human rights rather than merely to
impose a prohibition.
Two protective functions of the law have been dominant, namely,
protection against discrimination and the protection of confiden
tiality for people with HIV or suspected HIV infection.

rights
human
In the area of protection against discrimination,
instruments have been invoked in the interests of people with
HIV.
In relation to protection of confidentiality,
confidentiality, the law has been
invoked in a range of different ways.
It has been used
f or
example, to uphold obligations of confidentiality relating to
information about HIV status obtained by a hospital, to provide a
remedy for defamation in a case of disclosure of HIV states and
in some cases to justify withholding the identity of an HIV
infected blood donor.

that apply in the event
remedies
of
Legal
unjustified
discrimination or breaches oF confidentiality must be recognised
as dealing only with the symptoms of the problem and not with the
cause which lies in community prejudice and lack of sensitivity
to the rights and needs of people with HIV.
Both the proscriptive and the protective models for legal
inter
vention involve fundamental value judgments and often,
value
conflicts in relation to what should be protected and what proEach model operates on two levels: first by defining
hibited.
specific legal rights and obligations, and second by creating
reflecting certain values and rejecting others.
The instrumental role of law
The third model suggests that the law can play a proactive
role
in seeking to change underlying values and patterns of
socia1
interaction that create vulnerability to the threat of HIV in fection .
An appreciation of the potential role of the law in this context
in feerequires an appreciation of the emerging patterns of HIV
the
tion during the 1990’s. Increasingly, it has been observe^
disease is one that affects people in socially and economically
disadvantaged position.
The burden of HIV infection in the years to come will
be borne
mainly by the people in developing countries, including India.

fhe most vulnerable people are those who are denied the means of
protecting themselves against the risks of HIV because of lack o ;•
in formation j, economic need or powerlessness to control the basis
upon which their sexual relationships take place.

S

to
The challenge of HIV / AIDS policy is to recoonise the need
address not only what might be called the "HIV / AIDS specific"
into new
such as HIV education programmes
programmes and research
issues,
methods to prevent HIV transmission, but also the underlying lack
of awareness and social and economic factors.
The changes required are enormous. Can
Lan the law be used
instrument to provoke or reinforce these changes?

as

an

Poverty and economic dependency may lead to sale of sex as the
person's only means of income. Women may be denied independent
ownership of land. Law reform in this area could have an a|mmediate impact on patterns of economic support.
In turn they c ou 1 d
assist in reducing reliance upon sexual activity as a sourtce of
income and vulnerability to HIV.
Similarly, laws which require
minimum levels of participation and representation of socially
disadvantaged groups in the policy process, can help to ensure
access to relevant information about HIV and to take appropriate
measures.
Law is an important expression of social and cultural values.
It
can be used to change these values.
Where laws uphold (fertain
customs or behaviours that give rise to HIV transmission risk .
I he abolition of these laws can provoke a questioning pf
the
customs and values that underpin them. 1 he active prohibition of
certain conduct which may hitherto have been considered accept
able but which places individuals at risk of HIV can also be a
There is therefore, a need to harness
powerful force for change.
law in all its manifestations - proscriptive, protective, instrumental or otherwise - and to use it to promote rather than impede
the changes necessary to reduce the spread of HIV.

ETHICAL ISSUES
HIV infection and AIDS raise a large number of ethical issues.

1.

Those connected with testing
i)

Informed consent.
Can testing be done without informed consent?
Testing
should be done only with informed consent,
Without inproper counselling (pre and post test)
formed consent,
cannot be provided.

Pre and post counselling are necessary,
If the perpon has
tested positive, it is necessary to have post-coun sei ling
and psycho-social support.
Post-test counsellihg
is
as the person
necessary even if the test is negative,
negative.
Further,, the test may
would have developed anxiety. Further
have
been in the "window period", when, though infection is
present. the?
the response may not have been sufficient to
produce a positive result,
There is also the
possibi1ity
that the person may develop a false sense of security
which can tempt the person to continue the risk behaviour.

6

ii)

lestinq on the request of a third partv ,
Government,, educational institutions and employers may ask
for
testing.
Such testing,
without consent
violates
privacy and autonomy.

.1 i i )

Testinq for HIV (screening and confirmatory ) is expensive,
Extensive screening tests are a drain on the resources and
may not be justified when the likelihood of HIV
positives
in the population is small.

iv) Givinq out the information to the person tested.
In formation
should be given only after
the conf irnja tor y
test
results,
is
Often,
information
given
when
the
test
screening
positive,
result comes as
Con firmatory
tests,
take time, may be negative.
which
by
But
that
time,
psychological
and
social damages
have
may
been
caused.

2.Discrimination
i)

Denying
treatment.
The
initial
reaction
to
an
HIV
in fee ted
person is trying to avoid treating the
patient.
I here is fear of being infected,
Can a doctor or hospital
refuse to treat an HIV positive or AIDS patient ’?
"It
is unethical to refuse treatment or investigation
on
the ground that the patient suffers from a condition w h i c h
could
expose the doctor to personal risk or on the
basis
of moral judgment of the patient's life style”.
- General Medical Council,

UK,

1988.

the Medical Council of India code
Medical
What does
of
"The doctor is not bound to treat
say?
each
Ethics
and
everyone seeking the services, except in emergencies,
He
is free to choose whom he will serve”.
The general consensus is that it is the duty of
to provide all needed medical care.
ii)

the doctor

Not giving employment or discharging from employment
I he
may not be recruited, even
otherwise
though
person
suitable.,
because of the fear of liability later
on
for
medical treatment or that the co—workers may not want:
him
her to work with them for fear of getting infected.

i i i ) Mora 1 Jud qment
As
the infection is often associated with socially
ceptable behaviours (homosexuality, multiple sexual

unacpart-

ners, intravenous drug use)., society may shun the
and the family.

person

5. Confidentiality
Confidentiality is part of the larger issue of a patient's privacy. Confidentiality is informational privacy.

will respect the secrets which are confided in me even
"I
the patient has died". - Geneva declaration.

af ter

Are there situations in which information about HIV status can be
to a third party? Can it be given on grounds of risk to
given
public safety? Should a doctor reveal the patient's infection to
his or her spouse, to his or her children and others living w i t h
the patient?

"I here are grounds for disclosure only where there is a Serious
identifiable risk to a specific individual, who, if r ot so
and
(high risk persons, eg: sexual partners; this does not
informed
to
apply to health care workers - low risk) would be exposed
- General Medical Council, UK, 1988.
infection

4. Blood donation
When a 'heal thy'
All blood for donation must be tested for HIV.
would-be donor tests positive for HIV, should the person be? told
of the result?
There is need for the donor to be aware of the HIV status, 50 as
to prevent infecting others.
But the donor has the right to
There are many professsiona 1
choose whether to be told or not.
donors who are HIV positive and yet continue to sell
blood at
blood banks.

Quarantine

HIV
Can we set up quarantine arrangements for patients with
Unlike other infectious diseases, quarantine Ln the
infection?
The
long .
patients with HIV infection has to be life
case of
prospect of being 'imprisoned'
'imprisoned'' for life would make the person
dodge detection. Quarantine for life curtails the individuals
1iberty,
6. Allocation of resources
I here is need to allocate resources to prevent spread of infecAt present,
tion and to fight AIDS and intercurrent infections.
there is no effective medicine or vaccine against AIDS or HIV.
Whatever medicines are available can only relieve symptoms and
The
life.
They are also expensive.There is no cure.
prolong
same resources could save the lives of many suffering from other
has
diseases, from which cure is possible. A judicious decision
to be made.

8

i

‘M*

CONFLICTS

AND

CONFLUENCES

ANCIENT

MEDICAL

IN

DR.

ETHICS

C.M.

FRANCIS

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Proofs to

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Telephone:

Bangalore :

sent

INDIA

ETHICS

to

given

above

(Office)
(Residence) S53c^o3

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CONFLICTS

9

ETHICS

IN

AND CONFLUENCES

ANCIENT

AND

MODERN

MEDICAL

INDIA

by
Dr. C.M. Francis Director
St. Martha's Hospital
Bangalore, India
Contents

1. Introduction
2.

Informed consent

3. Unethical practices - advertisements - diagnostic aids - drugs and pharmaceuticals
4.

Right to health - health policy - demands of the few versus needs of the many.

5. Control of fertility
6.

Right to life - abortion - female foeticide - Infanticide - euthanasia

7.

AIH / AID / Surrogate mother

8.

Medical education

9.

Organ transplants

10.

Terminally

ill

References

Annexures :

1.

India

2.

Informed consent

3. Control of fertility

CONFLICTS
MEDICAL

1.

AND

CONFLUENCES

ETHICS IN

ANCIENT AND

MODERN -

INDIA

INTRODUCTION

India is the second most populous country and the largest democracy in
the World.

It had an estimated population of 818,800,000 in 1988 (See annexure

for demographic details and health indices).
India has a rich cultural heritage. Ancient Indian thoughts, philosophy and
ethics, developed with a rational synthesis, went on gathering into itself new
concepts. They kept pace with the progress of thought and were not remote
from popular understanding.

Spiritual experience was the foundation

of India's

cultural history. Next to spirituality, dharma (ethical conduct according to one's
state) was the most important concept of Indian thought. This cultural heritage

often influences and sometimes confronts new thinking, especially, those originating

from other cultures.

Dr. S. Radhakrishnan, a former President of India and Professor of Oriental
Philosophy, University of Oxford says:

Reverence for the past is a national trait. There is a certain doggedness
of temperament, a stubborn loyalty to lose nothing in the long march of the
ages. When confronted with new culture or sudden extensions of knowledge, the
Indian does not yield to the temptations of the hour, but holds fast to his traditional
faith, importing as much as possible of the new into the old.

Conservative liberalism

is the secret of the success of India's Culture and Civilization"

The value systems in India have been influenced by all the religions, but
mostly by Hinduism, the major religion (82.64% of the population), contributing

to the philosophy and ethics of the people of the country.

The fundamental

basis of ethics arises from the Hindu belief that we are all part of the divine
Paramatman; we have in each of us Atman, part of that Paramatman. The ultimate

aim is for our Atman to coalesce with Paramatman or Brahman to become one.

b

According to the Vedas (4000 B.C. to 1000 B.C.), the call to love thy neighbour
as thyself is "because thy neighbour is in truth thy very self and what separates
you from him is mere illusion (maya)".

Hence the conduct of a doctor (like any

other person) will be one of love and therefore, ethically sound; the patient and
the doctor are part of the same.

Closely allied to Hinduism are Jainism and Buddhism. These religions proclaim
K

Ahimsa

Paramo

Dharma"- Most

important of all our actions is ahimsa, which

is usually translated as non-violence, as enunciated
Gandhiji, even to obtain political freedom.
of ahimsa goes beyond non-violence.
"Sarvatha

by Buddha and practised by

However, the Indian traditional concept

Patanjali defined ahimsa as

Sarvada

sarvabutanam

anabhidroha" ,

a complete absence of ill-will to all beings.

Ayurveda, the ancient science of life, lays down the principles of management
in health and disease and the code of conduct for the physician.
described

the

of

medicine

two

fold:

and combating disease (swasthaduraparayanam

cha).

objective

vision of the role of the physician!
life-style:
physical

cleanliness

discipline.

and

everything:

body),

preservation

of

good

health

How close to the emerging

Ayurveda emphasised the need for healthy

good

diet,

proper

behavior,

mental and.

and

This is carried out by proper dinacharya (daily routine) and

rtucharya (according
in

purity,

as

has

Charaka(lO)

to seasons).

jalasuddi

(pure

Purity and

water),

cleanliness

aharasuddi

(clean

were

to be

food), dehasuddi

manasuddi (pure mind) and desasuddi (clean environment).

been primarily the science

observed
(clean

Ayurveda has

of health and then only the science of the cure of

disease and cure of the ill.

Ayurveda calls upon the physician to treat the patient as a whole:
"Dividho
Sariro

jayate

vyadih

manasasthatha

Parasparam
Nirdvandvam

tayorjanma
nopalabhyate"

(Diseases occur both

Aswamedha parva of Mahabharata.

physically

and

mentally

and

even

might be dominant, they cannot be compartmentalised).

though

each

part

... 3
I

The

ancient

Ayurvedic

system,

influenced

by

the

man as a whole - body, mind and what is beyond mind.
of Indian

Upanishads

treats

The earliest protagonists

Medicine, such as Atreya, Kashyapa, Bhela, Charaka and Susruta have

based their writings on the foundations of spiritual philosophy and ethics, formulated
But the one teacher of Ayurveda who established

by the ancient rshis (sages).

the science on the foundation of spirituality and ethics was Vagbhata, the author
of Astanga

Hridaya

Sukarthah

Vagbhata says:

sarvabutanam

Matah

sarvah

Sukham

ca

vina

dharmat

thasmad

dharmaparo

bhavet.

(All activities

na

pravrthayah

man are directed to the end of attaining

of

happiness is never achieved

without righteousness.

happiness,

It is the

whereas

bounden duty of

man to be righteous in his action).

Vagbhata further declares that it is the duty of any
who are afflicted to the limit of his

man to serve those

ability (serving even the lowliest creatures).

Charaka Samhita has elaborate code of conduct; the medical profession
has to be motivated by compassion for living beings (bhuta-daya)V
Char aka's
humanistic ideal becomes evident in his advice to the physicians/"He
who
"He
practises not for money nor for caprice but out of compassion for living beings
(bhuta-daya),

is

the

best among all physicians.

of religious blessings comparable to
for his patients.

Hard is it to find a conferor

the physician who snaps the snares of death

The physician who regards compassion for living beings as the

highest religion fulfils his mission (siddharthah) and obtains the highest happiness".

Medical Ethics in India today is in a flux because of the impact of develop
ments in the West on the ancient concepts as also the socio-economic situation
The problems are
(1)

those concerning the professional

activities of the doctors and related ones

(ethics of trust vs ethics of rights, eg., informed consent and rights of patients),
(2)

those connected with social justice and equity, including the use of sophisticated
technology,

experiments on human beings and right

of many), and

to health (unmet needs

r

o
.... Q

(3)

2.

those related mainly to the beginning and end of life, including right to life.

INFORMED

CONSENT

is

There

a

general

to get 'informed consent'
are unable

patients

India

that it is not possible

because of rampant illiteracy,

They believe that the

belief among doctors in

to make a reasoned choice

because they cannot appreciate

the intricacies of alternative medical treatment, procedures or drug trails.
a paternalistic view is taken:
troublesome

and

time

"the doctor knows best".

consuming.

Why

take all

Giving information is

trouble when1 the

the

Often

patient

will anyway agree to what the doctor suggests? Is not consent implicit in the
very fact that the patient has sought the expertise of the doctor?

Dr. Srinivasamurthy and colleagues
Health

and

Neurosciences,

Bangalore,

obtaining informed consent.

(20)

at

the

conducted

a

National
study

Institute of

into

the relevance of

Almost all (99%) of the subjects invited to participate

in a drug trial gave a clear choice whether to participate or not.

Their decision

Patient's level of understanding

was based on adequate information being supplied.
and

Mental

to the amount of information provided.

decision-making related

They

did

not correlate with social, economic, educational or other background characteristics.

Can

the

doctor

withhold

treatment,

if

there

is

no

'informed

consent'?

There seems to be conflict between the moral duty of the doctor and the legal
rights of the patients.
allowed

to commit suicide.
and

treatment
On

the

According to present law in the country, a man is not
Can
Can a
a man refrain from benefitting from medical

forfeit saving his life?

Will

the

doctor

be assisting

suicide?

contrary, does not the patient have the right to determine what shall

be done to his/her body?

What

is

the

status

of

'informed consent'

when

a patient is admitted to
the hospital in a critical condition but in full possession of his/her senses? Can
the surgeon who diagnosed
operate

on

the sole ground

the operation?

the condition requiring
that the patient had

immediate surgery
not given his/her

refuse

to

consent for

If by the doctor's refusal to undertake the operation the patient

later dies, what is the liability of the doctor?

6

D

with

An interesting case came up in the State of Kerala recently. A patient
acute abdominal pain was admitted to a Government hospital.
He was

examined by

the duty doctor,

who diagnosed

the case as perforated appendix

with general peritonitis, which required an immediate operation. But the operation
was not performed by the surgeon and the patient died the next day.

was laid against the doctor personally for pecuniary

An action

damages by the patient ’s

dependents and against the Kerala Government vicariously.

The doctor ’s defence

was that the consent of the patient was necessary before he undertook the operation

and, as the patient did not give it, the operation was not done.

The court rejected

this plea and granted a decree against the doctor personally, absolving the Govern-

ment however.

The decree was confirmed by the Kerala High Court in the appeal

preferred by the doctor (Annexure 2).
Two specialist Surgeons who were called as expert

witnesses stated that

they would have operated on the patient without the explicit consent.
Dr.
(personal

A.

Ramaswamy

communication)

Iyengar,

Director,

R.V. Institute of Sanskrit Studies

says "Informed consent of

patient is not required.

Faith in the doctor is more important on the part of a patient rather than his
intellectual compliance or otherwise".

This is the general view of the public

and the majority of doctors in India today.
Contrasting to the above is the view that every human being has a right
to determine what shall be done with his or her own body; a surgeon who performs
an operation without the patient's consent commits
r ki U?)
liable
"In

an assault for which he is

the medical context, the mere fact that one puts oneself into

hands of physicians does not mean that they can proceed as they see fit.

the
They

have a duty to explain what sort of treatment they propose and why and to point
out significant risks or reasonable alternatives.

They also have a leg^l duty

to limit treatment to that to which one has consented.

If they go beyond the

boundaries, even for the patient's good and with good results, physicians violate
(g)
the patient ’s right" - Angela RoddeyHolder . Indian physicians who are trained
abroad or have imbibed this principle find themselves in a conflicting situation.

... o

r

r

What

is

the

ancient

teaching

in

such

circumstances?

Charaka advises
the physician to take into confidence the close relatives, the elders
in the community and even the State officials, before undertaking procedures which might
end in death of the patient.

The physician is then to proceed with the treatment.

In India, ethics of trust has been and continues to be in vogue. But more
and more people are questioning the practice.

They want to make their decision

especially in the light of what is happening in the West.
to accept mistakes, even if inadvertent.
any harm done, attributing

They are not willing

The old idea to accept philosophically

it to karma or fate, with ethics of trust based on

'goodness’ of the doctor is slowly giving way to ethics of rights.

‘ 3.1

UNETHICAL
It

TREATMENT

is a common

everyday

experience to see sharp practices

treatment: they are sometimes advertised through
made, which are unjustified.

the media.

The unsuspecting masses

of unethical

Claims are often

fall a prey to these promises

of cure and relief.

But we find such practices in the developed countries also.

The

King's

case

recent

at

College

Hospital,

London of a haemotologist

and a

veterinarian, who claimed to have developed immunotherapy against AIDS illustrates
it. In the

matter of unethical treatment,

the difference between the developed

countries and the developing countries seems to be like that said to exist between
capitalism and socialism.

When asked the difference between the two, the reply

was " There is a big difference. Under capitalism, man exploits man.
it is the other way round."
with

its

of the

mass of

situation.

illiterate

Under socialism,

But such practices are much more common in India,
and gullible people.

Some

doctors

take advantage

Other doctors, who know about such charlatan

practices, do

not expose the cases.

The ancients frowned upon such practices.

3.2

UNETHICAL

There
are

frowned

ADVERTISEMENTS

are a few instances of unethical
upon

by

their

colleagues

but

advertisements by doctors.

little action

follows,

These

The Medical
is to look into such matters but because of technical flaws,
the doctor
often escapes.
Council

Recently, advertisements by hospitals and diagnostic centres are coming

r

r

wav claiming that theirs is superior
up in a big
bis way

to others.
others,

This is producing

problems. "It is totally unethical. I think any agency worth its name will not
advertise in such a manner", Joe D'Silva, General Manager, Imageads

Reddy,

Creative

W . M r. Vikram
1

Director, R.K. Swamy, says "If I were heading an agency,

will not resort to such unhealthy advertising". But it is the general trend in the
country in all commercial,

industrial advertising.

affect the "health industry" also.

Such practices are bound to

Professional ethics is seen only as a specialised

part of general ethics.
There is little guidance from the ancients because there were no advertise
ments.

3.3

DIAGNOSTIC AIDS
There is a growing

supermarket in diagnostic equipment. Sophisticatet equip-

ment is bought by third world countries at great expense of scarce foreign exchange.
Most of the imaging equipment currently in use in the various hospitals and diag

nostic laboratories is excessive when related to the needs and the complexity
to operate and maintain.

The great majority of the people cannot have the benefit

of even the most elementary x-ray examination.
Third world countries are sometimes used as dumping grounds for equipment
not needed elsewhere or substandard diagnostic aids withdrawn from the developed
countries.

A glaring example was the sale of defective diagnostic kits for AIDS,

India is suffering because India was not cautious enough in ordering AIDS kits
from

a

West German

multinational.

These kits were substandard

with many

false negatives,

AIDS control programme got into jeopardy because the kits

were unreliable.

It masked the extent of the prevalence of AIDS in the country.

Enquiries with the West German control authority revealed that the lot of kits

supplied to India (including those supplied to the Indian Council of Medical Research),
were those recalled from European market early in 1988.
Yet another

problem with the purchase of

been the difficulty of

servicing

and maintenance.

equipment
Doctors

from abroad
trained

abroad

has
in

of the specialists are understandable. But should not these need
t

■?

by the realities of the situation?

to be tempered

The equipment may function for some time.

When they go out of order, there is no back-up service.
equipment lies idle.

Net result is that the
The doctor also is unable to deliver the goods.

Is it ethical for the doctor to order for costly, sophisticated equipment,
which is not likely to function, utilising scarce foreign exchange?

Is it ethical
for firms to supply these items without back-up service? This is
is a problem in
(21) suggests that
most third world countries.
Thairuv
"an ethical code should
be agreed on by both (manufacturers and users) regarding the sale of equipment".

3.4

DRUGS

AND

PHARMACEUTICALS

There is a huge proliferation of drugs in
i
the Indian market, with more
than 60,000 formulations,
tin-shed

factories

They are manufactured by large, medium, small and
and national.

multinational

Many

of

the

small

factories work on the basis of 'loan licences’ from the large firms.
industries are not subjected

scale

to the

and

tiny

These small

more stringent rules and regulations.

The larger firms then market the product under their brand name.

There are
countries.

There are drugs which

marketed,

be

after getting

take a long time.
drugs,

many drugs in the Indian market which are banned

patients

in other

were banned in India itself but continue to

'stay'

orders

from

the

courts.

Legal

proceedings

During this period, doctors continue to prescribe these hazardous

continue

to

take

them

and

the

firms continue

to

make

huge

profits.

Many of the drugs in the market are spurious or of substandard quality.
It

has

been reported

substandard.
they

are

that as a rule

20-30 percent of the samples tested are

These are products manufactured by firms irrespective of whether

national

or

multinational.

Government

agencies

take a long time to

test the samples and to announce the details of the substandard drugs.

Long before the announcement, the particular batch of drugs would have
been prescribed by the doctors and consumed by the users; many will not notice
the announcement, which will be made in the local newspaper but the drug is
Most manufacturers do not recall
sold countrywide.
the
banned
products.

Manufacturers

D

side

expected

are

to

effects and adverse effects.

give

the

contra-indications,

indications,

They often do so but in such a way

that it

will not attract attention: the greater the hazard, the smaller the print.

"One

of

the

most

distressing

aspects

of

the

present

health

situation iin

India is the habit of doctors to, overprescribe or to prescribe glamorous and costly
drugs with limited medical potential.

It is also unfortunate that the drug producers

try to push doctors into using their products by all means - fair or foul.

These

basic facts are more responsible for distortions in drug production and consumption
than anything else.

If the medical profession could be made to be more discrimi

nating in its prescribing habits, there would be no market for irrational and unnecesJ9)
rl
sary drugs.

The drug firms do not generally follow the WHO ethical criteria for drug
promotion.
as

Gift giving is rampant in the country and raises many ethical issues

in other countries (2); the effects are

In

the ancient days,

the

more pronounced

in a poor

country.

medicines were prepared in India (as elsewhere

in the world) under the personal supervision of the physician or by the families
of

the patients.

There

strict guidelines for the collection of

were

the herbs

and other raw materials and for the processes. The medicines thus prepared were
Today, even

reliable for quality and purity.

Ayurvedic medicines are prepared

on a commercial scale and what applies to modern pharmaceuticals applied equally
to Ayurvedic drugs.

4.1

RIGHT

TO

HEALTH

"Everyone

has

and

well-being

of

and

medical care

the

right

himself
and

to a standard of living adequate for

and

of

necessary

declaration of human rights.

his family, including food,

the health

clothing, housing

social services" - Article 25 of

the Universal

If health is considered a fundamental human right,

it becomes the basic responsibility of the State to protect and promote the health
of all the people.
to all.

There has to be an irreducible minimum of health care services

It is both ethical and legal.

»
The Alma-Ata conference called for a new approach to health and health
care, to close the gap between the 'haves' and 'have nots', achieve more equitable
distribution of health care resources and attain a level of health for all citizens
of the world that will permit them to lead a socially and economically productive
life.

The

health of

Conference

declared

the people, which

have

"Governments

a

responsibility

can be fulfilled only by adequate

the

for

and equitably

distributed health and social measures".

The

right

to

health

brings

on another

issue

of

distributive justice

health

care

to all.

One important aspect of such service is the presence of qualified persons

delivery:

to

make

available

an

acceptable

in

for health services, where such services are not available.
be compelled to provide
services?

and

affordable

care

Can the physician

service to areas otherwise unable to obtain medical

Can a compulsory

rural service be prescribed?

institutions generally subsidise medical education.

The State and the

Even if there is no subsidy,

the doctor has been provided an opportunity, not available to many. St. John's
Medical College, Bangalore, has made it mandatory that the medical graduates
serve

minimum period of

for a

two years in an underserved

rural areas.

A

few other Medical Colleges in the country also require the medical graduates
serve in underserved

areas.

owned

or

by

the

people

But opposing questions arise. The doctor is not

the institution. Can the doctor be deprived of the

right to earn legitimately as much as he or she can and where he or she can?
Can a person be compelled to act against his or her wish as long as no harm
is done to the Society?
the

people

The consensus is that the doctor owes a duty to serve

the areas where

in

they are needed but the medical

profession,

in general, is not in favour of mandatory service.

Health is not a fundamental human right under the Indian Constitution.
But the subject is included in the Directive Principles of State policy, which
is considered
the

as

constitution

the

'conscience'

of

directs the State

the Indian

Constitution.

Article

to make policy to ensure health;

39 of
article

^7 requires the improvement of public health to be among the primary duties
of

the State.

number

of

In pursuance

policy

statements

of

these articles

and

programmes.

the Government

had issued

a

The latest in the series is
the National Health Policy (1982), approved by Parliament by
the end of 1983.

I

What rights do the people and patients have? About 25 million children

4

in India are estimated to go blind every year for want of care. It is mainly
due to Vitamin A deficiency.

Many of these children die within weeks of

Even children with milder forms of Vitamin A deficiency

becoming blind.

succumb to infections and malnutrition. Do they have the right to be protected

against the deficiency?

There are about 300 million people living in areas

where

the soil is deficient in iodine. The Government is belatedly taking

action

to provide iodinised salts.

The iodine deficiency diseases - endemic

goitre, cretinism and others- had

been known to the doctors in the country

for

long time but they did not raise their voice to prevent the deficiency.

Similarly there are millions suffering from other deficiency and communicable
diseases, often caused by the faults of the society in which they live, and
lack of concern and action by the Government and the people, including the
medical profession.

^.2

HEALTH POLICY
There can be little objection to the stated health policy of the Government

of India but when it comes to implementation, it is another story. The allocation
of resources to the health sector has been very small.

Often, the priorities

are assigned based not on the needs of the people but on what is fashionable.
An outstanding example will be a comparison of the efforts made on
what may be described as the diseases of affluence and diseases of poverty.

The country ’s needs are primarily to prevent and manage diseases of malnutrition
and infection.
and developing

But most of the money is spent in obtaining sophisticated gadgets
centres to treat degenerative

cardiovascular (there are at

least QO centres for open heart surgery) and renal diseases.

Very little is

made available to manage the infectious diseases which take the major toll
with respect to morbidity and mortality.

A prime example in recent times

is Kala-azar in the villages of Bihar, Orissa and West Bengal.

The whole east

coast of India is vulnerable to the resurgent attack of kala-azar (a disease
caused by Leishmania donovani). The efforts to prevent the disease and manage
the outbreak have been poor, So also is the case of other common communicable

diseases.

Questions arise:

Who shall receive what health care ?
What resources can be allocated, how and to whom ?
How do we set our priorities ?
What is an acceptable form of health care ?
Who should decide on health policy ?

These and many other issues are being debated currently.
for more equitable distribution

There is a wave

of the benefits of medical knowledge.

But

against it is the much more powerful force for the use of sophisticated, specta
cular and costly technology for the benefit of the few.

Newer gadgets, machinery and technology are skyrocketing the expenses
for diagnostic and therapeutic procedures.

People are directly and indirectly

pressurised through various media to go through a whole array of expensive
diagnostic procedures.

Patients are made to feel that, unless they go

all the sophisticated tests, a correct diagnosis is not possible.
reasonable

diagnostic accuracy to near

through

"Moving from

100% certainty is so expensive that

the business creed of cost-effectiveness is of major importance and is already
clashing with the physician's ethical wish to do the best for each individual,
regardless of income.

That last 10% of accuracy often accounts for 90% of

the cost and does not necessarily bring an equivalent benefit to the patient"
There are wide networks of costly diagnostic laboratories, aided and abetted
by doctors, who often get kickbacks.

Patients are
physicians
sums of

and

the

completely

mystified by the advice they get from

advertisements by

the

laboratories. They shell

their

out huge

money (relative to their earnings) which they can ill afford.

The

ethical onus rests squarely on the medical profession. In the words of Prof.
(18)
Ramalingaswamy
, the dictum should be "maximum benefit to the patient
with minimum Hazards and cost".

Does an individual have the right to buy expensive technology by the
exclusion of others who share the same resources ?

Can a person as an individual

because he has the money or is sponsored by the State because of political
or economic power or influence, seek and get high and sophisticated technology,

not available to others in less fortunate circumstances ? Is it right that the
scarce resources of qualified and experienced personnel, money including foreign
exchange and materials be used for the benefit of a few while the large majority
of people are not able to get even simple health care services ?
All religions advocate the care of the poor and needy.

Christ declared:

"When you have done this to the least of my brothers, you have done it to
me".

Gandhiji said: "I will give you a talisman. Whenever you are in doubt

or when the self becomes too much with you, apply the following test: recall
the face of the poorest and weakest man you have seen and ask yourself, if
the step you contemplated is going to be of any use to him.
anything by it?".

Will he gain

This had not been the ancient thinking. "Physicians had been

enjoined to give special care to the health needs of kings and those in authority.
But Kabir on Justice in Guru Granth Sahib said: "The valiant fighter is only
he who fights for justice to the poor".

Changes are taking place throughout the world in the concept of providing
health care.

Alma-Ata declaration of Health for All is one such.'

a signatory to the Declaration.

India is

Oregon in USA has recently considered the

need to advance the health of the population as a whole versus doing everything
for each individual patient.

Legislators have decided to cut off Medicaid funds

for organ transplants and to use the money thus saved to extend the basic
(6)
services.
The debate goes on: Shall the State purchase

12 renal dialysis machines

(which will maintain the life of a few sick people) or employ fifty community
health workers (to help 50,000 people achieve better health) ? Shall the hospital
buy one lithotripter or expand its programme for oral rehydration for children
affected with diarrhoea ?

The cake is small. How shall it be cut ?

Has the medical profession any ethical responsibility in influencing the
health policy ?

The doctors in India are often passive spectators in the figh-t

for social justice and against discrimination in health care.

CONTROL

OF

FERTILITY

The Government of India and the people of the country are concerned with
the increase in population.

The Government thinks that the benefits of economic

development are not seen because of the excessive growth in population.

Hence,

the Government wants to control growth by any means.

One method proposed

is that of

incentives and disincentives - incentives

to those who subject themselves to sterilization and disincentives to those who
are not willing to undergo sterilization. "Green card lure: the Bihar Health

Depart- •

ment has annonced that it will issue green cards to couples with two or less children
and who have undergone

sterilization after April

1985.

The cards are to be a

ticket to top priority in education, health and housing".

Such discrimination

raises an ethical issue.
Why should a third or fourth
child suffer from handicaps in education,
etc. in comparison to other children ?
The educational and other facilities in the
country and especially so in the villages
are limited. Discrimination in favour of one works out to be discrimination against
another.

The majority of leaders in the
is necessary.

country consider that control of population
The difference in opinion
opinion is
is with
with respect
respect to
to the
the methods.
methods. "If family

it certainly
planning is required, as it
certainly
inevitable"- Dalawari, a Sikh
leader
Sikh leader

is, artificial
methods of
is,
of contraception are
artificial methods
(personal
communication).
"It is essential
(personal communication).

to control effectively population growth. All methods for control of population
growth can be used", Swami Rangananthananda, Head of the Ramkrishna ashram,
Hyderabad (personal communication).

But there are others (a minority) who do not subscribe to the view
ation explosion.
myth.

According to Dr. Ravi Duggal,(5)

the

"population

of popul-

bomb"

is

a

Demographers and economists present a simple conclusion, that the high

population growth is responsible for the adverse standard of living.

The Government

accepts this theory, lock, stock and barrel, because they have to explain unemploy
ment, poverty,

disease,

pestilence and general

not agree (See Annexure 3 for his arguments).

misery,

According to

Dr. Ravi

Duggal does

Dr. Duggal, the population of India (as of other developing countries) will stabilise
once the spurt in
growth disappears after the industrial development,
as has happened in the affluent

countries.

Even when contraception (artificial) for fertility control is not practised,
certain medical procedures may

be done in certain situations which result in

contraception but the primary motive is to give full protection to the patient.
There are certain problems which are peculiar to under-development and
lack of adequate medical care. There may be women in whom the uterus may
tend to rupture or has already ruptured when they seek and get medical help,
because of inadequate health care services.

The child is delivered and then

the option is to do a hysterectomy or tubectomy, to prevent further conception
and possible rupture of the uterus and death of the mother or at least grave

'

consequences.

There is the dilemma : should the doctor (and the hospital) do a tubectomy
(a simple operation) with the purpose of preventing further conception (contra
ception) or carry out hysterectomy (a much more serious operation) which has
the ultimate consequence of preventing conception ?
Can sterilization receive its justification from
when there is no immediate life-threatening situation ?
"If

valid medical reasons,
Bernard Haring^ says:

a competent physician can determine in full agreement with his patient,

that in this particular situation, a new pregnancy

must be excluded now and

forever because it would be thoroughly irresponsible, and, if from a medical
point of view, sterilization

is the best possible solution, it cannot be against

the principle of medical ethics nor is it against natural law".
At present, the physicians in India decide taking into account the overall
effect, present and future, on the total health of the person.
In the

ancient writings, artificial

methods of

with natural processes were advised against.

contraception,

interfering

But the Upanishads (Taithiriya)

and Dharmasutras (Manu) enjoin that such codes of conduct are to be determined
from time to time by the elders and the opinion leaders of that time as dictated
by the demands of that particular time and place.

-

Article 3 of the Universal declaration of human rights declares: "Everyone
has the right to life, liberty and secruity of person".

Article 6 states:

has the right to recognition everywhere as a person before law".

"Everyone

The International

covenant on Civil and Political Rights (1966), article 6 states: "Every human
being has the inherent right to life". These and other declarations and affirmations
raise the question: How do we define a "person", a "human being"?

Upon the

answer to that question will depend the rights to life.

According to

ancient Samkhya philosophy, there are two ultimate principles

in the universe: Purusha (soul) and Prkriti (the body). The soul is immutable
(Kutastha)
and imperishable (nitya/?^.
The soul or atman descends into the
zygote, produced from the union of the sperm and ovum, along with the mind,
which carried with it the influences of major actions done in previous states
of existance.

"Life starts with the union of the sperm and the ovum.

is reckoned from that moment.
that

the

transmigrating

Individuality

It is at the moment of the sperm-ovum union

atman,

purusha (the individual) gets

his

material

encrustation, as dictated by his previous karma", Dr. A. Ramaswamy Iyengar
(personal communication).

According to the Catholic view point, a new human being comes into
existence from the moment of conception.
Indian thought.

This is in consonance with the ancient

All rights as a person accrue to the new human being and must

be respected as such.

Interventions on the new human being should be such as to maintain and
improve the quality of life.

Therapeutic procedures on the human embryo are

licit, if there is respect for life and integrity of the person (embryo/foetus)
and should not involve disproportionate risk.

The procedures must be directed

towards healing, improvement in health and survival.

The

growing child

in womb

cannot be considered as an object,

which

can be disposed off as thought fit by the mother or any other person. What
happens if an injury is caused to a foetus while in uterus ?

Can damages be

claimed ? If the answer is yes, then the child is a person. Can the life of this
person be ended by procedures approved by others ?

Most of the doctors in India do not wish to get entangled in the debate.

6.2 * ABORTION
The

Indian law allows abortion, "if the continuance of pregnancy would

involve a risk to the life of the pregnant woman or grave injury to her physical
or mental health".
Abortion was being practised earlier by many.
it was practised in a clandestine manner.

Because it was illegal,

The passing of the Act made medical

termination of pregnancy legal, with certain conditions, supposedly for safeguarding
the health of the mother.
From April 1972, Indian doctors started performing with zeal, abortions
at women's request.

Doctors advertised blatantly and invited women to have

abortions done at their clinics.
The

All these

have raised many ethical issues.

Government supported and encouraged abortions.

The Government

saw

it as one more method of population control.
Though abortion is legal,. many find it 'immoral',

But most people including

physicians in India do not see anything unethical or immoral in carrying out
medical termination of pregnancy

within the first trimester, for the 'greater

good' of the country in the light of the expanding population.
Abortion is severely condemned in the Vedic, Upanishadic, the later puranic
(old) and smriti literature.
Paragraph 3 of the Code of Ethics of the Medical Council of India says:
"I will maintain the utmost respect for human life from the time of conception".

There arises a conflict of the rights of two persons, the mother and the
growing foetus.

Has the mother the right to destroy the life of the child she

is carrying in her womb ?

Is the right something akin to the possession of

some material good, which can be disposed off as the mother wants, without
consideration of the right of the unborn child ?
"Ban urged on embryo sale for brain transplants" - so goes a headline
in a news report from New Delhi.

A Dutch doctor at the World Neurological

... is
Congress at New Delhi stated that international legislation is required to prevent
mothers from

selling

the

growing embryos for transplantation

brain into the brains of patients with Parkinson's disease.
’’this will be world wide reality within a few years”.

of

the

foetal

According

to him

A Chinese paper claimed

that doctors in a Chinese hospital have successfully treated ten patients with
Parkinson's disease with tissue taken from four month old embryos.

Is it ethical for the doctor to participate in the venture of women getting
pregnant and aborting the foetus for monetary considerations ?

6.3

PRE-SELECTION,

SEX

SEX-DETER MIN ATION

AND

FEMALE

FOETICIDE

There are a number of methods available for sex determination and sex
selection.

Like

traditional practices and

mores,

these methods of selection

are pro-male and anti-female.

Some doctors in India have been carrying out procedures for sex-determi
nation.

It is perhaps peculiar to India that pre-natal determination of sex is

employed for rejection of a female foetus.

If the test shows a female foetus,

at the request of the parents, the doctor performs an abortion.

Such abortion

clinics thrive in the country, in spite of public opinion against it.

But many

physicians continue the selective abortion of female foetuses, misusing prenatal
tests for sex-determination.

Professional organizations such as the gynaecologists

and obstetricians in Bombay have advocated social boycott of those indulging
in unethical activities like disposing of female foetuses after sex determination
test.

But it is not easy, as the Secretary of the Bombay Obstetric and Gynaeco

logical Society said because of the difficulty in conclusively proving such action.

The general opinion in the country is "to go for abortion merely because
it is a female child is criminal and sinful, but taking the situation in our country,
concerning

dowry,

status

of

women and

perennial

difficulties

and

hardships

for women and their parents, the attitude of people is understandable".

There

are quite a few persons who justify female foeticide in the Indian Society with
its social custom of dowry.

And there are quite a few physicians who would

like to take advantage of the possibility to make some quick financial gains.

J

The

Government,

though

proclaiming

against

female

seem to be too keen to effectively implement that policy.
because it helps in the control of population.

foeticide,

does

not

Abortion is encouraged

India has a sex ratio adverse

to women (935 women to 1000 men) according to the 1981 census.

The availabi

lity of sex-pre-selection and sex-determination and female foeticide will worsen
the situation.

6.Q

INFANTICIDE
There is a growing tendency in many parts of the world to do away with
life, if the newborn is detected with deformities, compatible with life but likely
to put a great burden on the family (eg., children with spina bifida).
much less in India.
karma.

This is

The parents accept the children as part of their fate or

But there is a growing number of persons who advocate that the choice

be left to the parents,

According to them "if the parents feel incapable psycho-

logically,

financially, to bring up the grossly abnormal child,

physically

or

would leave it to them to decide at birth.

1

To kill the child at a future date

would be murder".
There are also instances
is a female child.

where infanticide

is resorted

to because

it

There was a practice to do away with the newborn female

child, if the mother died during childbirth.

But Guru Amar Dass, the third

Guru of the Sikhs, opposed and condemned the killing of daughters immediately
after the death of the mother.
In the Vedic times, there is no reference to infanticide of children born
in wedlock, but there is reference to the exposure of the child by unmarried
(12)
women.
Manu advises the king to award death sentence to him who kills
a woman, a child or a brahmana.

"Neither in this world nor in the next can

any action leading to the injury of living beings be productive of good results.
The conduct of persons who do not perform vratas (religious ceremonies) but
whose minds are not given to killing can lead to heaven"

(19)

The great majority of physicians in India are totally against infanticide,
even when the newborn has many defects at birth.

6.5

EUTHANASIA

"Hasn't a person the right to quit a life which, according to him or her,
is not worth living ? Is the right to die not implicit in the right to live?"

India does not allow suicide nor aiding and abetting suicide.

But

there

have been questions raised. The Law Commission in its fortysecond report stated:
"It is a

monstrous

procedure to inflict further suffering on an individual who

has already found life so miserable, his chances of happiness so slender, that
he has been willing to face pain and death in order to cease living".

No documents allowing euthanasia in ancient times are seen. But there
were advocates among the ancient physicians for abandoning

treatment, when

the disease had reached a stage from which recovery was considered unlikely.

According to Hindu philosophy, that which is born must die to be reborn
according to her or his karma.

In Sikhism, death is not the end of life. The

soul merges with the Lord, io be put into another life at his discretion. Soul
is deathless and restless until it merges in the Lord.

Most people reject positive euthanasia, of bringing about death in an active
manner. The exceptions are among the intellectuals at present.

People, by and

large, accept suffering as part of their fate, resulting from karma.

But there

are many who favour the omission of treatment, with the intention of not prolong
ing the process of dying.

They also favour measures to relieve the constant

agony, suffering and pain, even if these measures might have a secondary deleteri
ous effect on the length of life.

7.

AIH / AID / SURROGATE

MOTHER

The desire to have children is a dominant one, to be fulfilled. What is
to be done when there are impediments to having a child in the natural way
and there is no way of overcoming sterility in one or the other partner ?
One way out is adoption. But many people desire to have their own children.

.

What do the ancients say?

According to Charaka Samhita, "the man without

progeny is like a tree that yields no shade, which has no branches, which bears
no fruit and is devoid of any pleasing odour".
a son.

India's social structure required

He is expected to provide support to the parents in old age.

He is also

required to perform certain religious rites on the death of the parents. A married
woman is under social pressure to conceive soon after marriage. A sterile woman
is considered inauspicious.

There has been a procedure of niyoga or appointment

with the wife or widow of the childless person
of a male to have intercourse
(12)
to procreate a son.
A widow may be appointed to have intercourse with the
husband to raise a son when the couple does not have a son.
There are a number of conditions necessary to allow niyoga:

(1)

The husband must have no son.

(2)

The

gurus (elders)

in family council should decide to appoint the widow

to raise an issue for the husband.

(3)

The male person appointed to have intercourse with the wife or widow (when
the husband is dead) must be

(^)

i)

the husband’s brother

ii)

a sapinda or sagotra of the husband (a close relation or belonging
to the same group) or a saparivara (a person of the same caste).

The person appointed and the widow must not be actuated by lust but only
by a sense of duty.

(5)

The relationship was to last only till one son was born (two according to
some).

(6)

The widow must be comparatively young.

If the stringent conditions are not met, he/she would be punished severely,
The very many restrictions imposed meant that niyoga must not have been very
prevalent.

While the ancient dharmasastras

like Gautama allowed niyoga, there were

other dharmasastras and writers almost as old as Gautama, who condemned the

r

D
j

practice and forbade it.■ Manu, for example, condemned it in the strongest terms
Instances of i
possible.
fwo^a, rare even in ancient times, gradually became rarer
still. By the first centuries of the Christian
era, it came to be totally prohibited.
To whom did the child of niyoga belong ? There

(1)

was difference of opinion:

If there was an agreement between the elders of the widow and the person
appointed or between the husband himself and the begetter, that the child
should belong to the husband, then the child belonged to the latter.

(2)

The son belonged to both the begetter and the husband of the wife.

The

modern

surrogate mother
The

methods
seem

main difference

motherhood.

of

artificial insemination by husband

or

to be technological variations of the ancient

is the possible commercialisation

in the case of

donor and
procedure.
surrogate

The motive may be different.

In the ancient system, there were no difficulties in the upbringing of the
child. With the joint family system (close knit
community), the child was readily
accepted as a member of the family.

8.

MEDICAL

EDUCATION

The process of training often determines the ethical
cian and the profession.

values held by the physi-

The emphasis given to

the teaching of medical ethics can
affect the professional behaviour of the future physician,
In general, today, there
is little emphasis on training in ethics and related subjects. There are a few except
There
ions but they do not constitute even ten percent of the institutions in the Country.
Dealing with instructions to medical students, Charaka^^

(1)

says:

Your action must be free from ego, vanity, worry, agitation of mind or
envy; your actions must be carefully planned, with concern for the patient
and in keeping with the instructor's advice.

4

(2)

Your unceasing efforts

must, at all costs (sarvatmana) be directed

giving health to the suffering patients (aturanam
(3)

You

must

never harbour feelings of ill-will

towards

arogya).
towards your patient, whatever

the provocation, even if it entails risk to your life (jivitahetor api api aturebhyo
nabidrohavyam).
(4)

Never should you entertain thoughts (manasapi) of sexual misconduct or thoughts
of appropriating property that does not belong to you.

(5)

Take no liquor, commit no sin, nor keep company with the wicked.

(6)

Your

speech

must

be

soft (salakshna),

truthful (satya), useful (hita)
(7)

oleasant

(sarmya),

virtuous

(dhanya),

and moderate (mita).

What you do must be appropriate to the place where you practice and the
time, and you must be mindful in whatever you do (smriti-mata).

(8)

Your efforts must be unremitting (nityam yatnavata cha).

(9)

Do not reveal to others what goes on in the patient's household (aturakula
pravarthayah).

(10)

Even when you are learned and proficient, do not show off.

Difficult

it

is to master the entirety of medical science, therefore,

one

must

be diligent (apramatta) in maintaining constant contact with this branch of learnihg.

According to

the ancients, medical wisdom is acquired by three methods

(upayani) :
(1)

study (adhyayana ), earnest and continuous.

(2)

teaching (adhyapana), after examining the student and ascertaining his character,
ability, health and interest and imparting lessons concerning life in general,
medical profession, medical ethics and science of medicine, and

(3)

academic

discussions

(tatvidya^sambhasha)

with

colleagues

students, in order to enrich one's own knowledge,

and

fellow

to obtain clarity of

knowledge and to get rid of doubts, to deepen one's understanding and
to learn new methods and ideas, and to become skilled

in expressing

one's thoughts.

Note

how

active learning

is placed

before teaching and

the

specific

mention of medical ethics among the broad subdivisions to be taught.
At the time of initiation, the student had to take
an oath.
But what
was more interestig was that the teacher also had tv lake an oatn: -wnen you
to take an oath: "When
on your part keep your vows and if 1 do not respond fully and impart all my
knowledge, I shall become
■ 2 a sinner and

my knowledge shall go fruitless."^.

One

major problem that has come up in recent times in the
r
UP 1" recent times in the country,
is the admission of students into "Capitation
"Capitation Fee
Fee Medical
Medical Colleges"
Colleges" based
based upon
the payment of a large sum by the student (or parent), usually Rs.300,000 to
Rs.400,000.

On the basis of such payment sometimes unaccounted, the student

is admitted.

Other
students, even though they may be far more 'merited'
Other students,

academically and otherwise are
are not admitted because they cannot afford
pay the large amount.

to

Because the basis of admission is the capacity to pay

the large amount to the management, many unhealthy practices arise.

The

whole environment becomes commercialised and vitiated; teaching and patient
care in these institutions are also affected.

9.

ORGAN

TRANSPLANTS

There

is

a

big

demand

for organ

transplants,

especially

for kidneys.

These demands and the means of meeting the demands often raise ethical nightmares because of unscrupulous activities.
There is a small group of transplants where close relatives donate their
kidney. This is poss.ble because of the strong family ties. But the large majority
of transplants are carried out on a commercial basis.

A British Urologist, Michael Vurvick, discovered that rich Indian
took their poor fellow countrymen as donors and paid them. He wrote a

patients
scathing

r

* article on Indian Surgeons and their unethical practices. But this happens with poor
people in other countries like Philippines, Turkey and others.

Turks were clandestinely

"exported" to Britain to supply organs to British nationals.

There
Doctors in India saw a potential goldmine in kidney transplants.
i add tion
were unlimited number of kidney patients from the rich middle east, in

to the rich Indian patients.

They were prepared to pay.

a commercial proposition.

A new class of agents or organ procurers rose up.

The doctors

involved were not

Kidney transplant became

bothered about the ethical issues of robbing a

A few doctors raised their voice: 'The
an unsuspecting person,
rong
trafficking that is taking place in kidney is ethically unacceptable, morally w

kidney from

and sociologically degrading" Dr. B.N. Colabawala, Urologist.

med
An estimated 100 kidney transplants involving foreign patients are perfo
every month in India (mostly in Bombav). Fees of Rs. 50,000 or more are chai-ged.
The donors get a small portion; the agents are also paid.

Those foreigners (mainly

from the middle east) who wish to avail of a kidney at relatively cheap prices

are making a beeline to Bombay.
It is not only illiterate

kidney.

people of the slums of Bombay that "donate'

the

Knowledgeable persons are also prepared to give away one kidney because

they are in desperate need for money.
A young lady working as a typist in Bangalore wrote to me a pathetic
letter: "1 am prepared to give my kidney for Rs. 20,000/- as I need the money

to pay for the dowry of my elder sister".
The people involved in the trafficking in kidney transplant will go to any
length, without bothering about the consequences.

Times of India, Bombay, O ct.20,

1989: "A 35 year old woman from Kashmir narrowly escaped receiving a kidney
of an AIDS carrier.

The transplantation operation was scheduled for tomorrow".

The man who offered to give a kidney for Rs.25,000/- is a professional
donor, an AIDS carrier.

blood

The donor had chosen to donate one kidney as he needed

the money. He could not get employment as he was AIDS positive.

In India, almost all kidney transplants are from live donors. There
been very few cadaveric transplants.

have

"All kidney transplants in India are at

There is no specific law which allows a doctor to take a healthy

illegal.

present

r

organ from a human being for a reason which is not beneficial to the donor's health."

The Times of India, Bombay, June 18, 1989.

10.

ILL

TERMINALLY

Physicians have been brought up to preserve life and to prevent death. The
ancient teaching has been that knowledge of incurability
make the physician withdraw care or treatment.

of the disease should Inot

As long as the patient breathes,

it is the duty of the physician to provide treatment (tatvat pratikriya karya yavae
chvasiti manavah/^\
But there is also another view: one should know when To
stop

treatment.

Among

the qualities that brought credit to the physician is the

withdrawal of treatment of one whose condition is definitely moribund (upekshanam
prakristheshu/lQ\
The two apparently contradictory dictums may probably mean
only that the heroic specific treatment was to be withdrawn and care to be given

to the terminally ill, to reduce suffering.
The present thinking is also in line with the above. Prolonging life with the
.help of

.machines when there is no chance of recovery or in patients suffering with

great pain and distress because of incurable illness has been questioned more and
more in recent times.
the physician

imminent,

If restoration of health is no longer possible and death is

need not do anything

living (dying) but it is proper and necessary

extraordinary or heroic

to prolong

to relieve pain and suffering.

measures have to be taken, even if they may incidently shorten life.

These

The physician

is expected to assist the patient in achieving a peaceful death.

TO

TELL

OR

NOT

TO

TELL

According to Charaka and other physicians of the ancient days, the physician

must be careful in telling the patient about the possibility of the incurable nature
of the illness.

the patient.
officials

Charaka advises that it should not be told bluntly.

It may shock

It is preferably made known to the patient ’s relatives and even to state

(fear of punishment,

should

the patient die under his care!).

Treatment

of a heroic nature is to be undertaken only with the consent of the relatives and
elders.

In modern days, doctors differ in their approach about how much and when

to tell the truth to the patient, while caring for the dying.
considerations:

A

study

There are many conflicting

the patient's right to know; the benefit to the patient; possible harm.

conducted

Research, Chandigarh,

in

the

Postgraduate Institute of

Medical

Education

and

ruth,
(11)
ill patients

showed that 69.2% of the doctors favoured telling the

while 30.8% did not believe in telling the truth to the terminally

Most of the doctors favoured involvement of the family members and close relatives.
In view of the family structure and the closer ties among the relatives in the

ndian

set-up, this aspect is of obvious importance.

CONCLUSION
We have moved a long way from the precepts and practices of the ancients.
This is true of ethics in general; the medical profession is also affected, to a greater
or lesser extent, by the changes.

Part of the change has been because of an erosion

of the values cherished in olden times; part of it is due to different thinking, influenced
to some extent by contact with other cultures; and part of it has resulted from the
advances in science and technology,
confusion.

The result has been that we are in a state of

We have been creating situations

to which

our ethical responses

been slow to develop or even unable to develop. What is the way out?

have

Perhaps, a

judicious blending of the ancient with the modern, integrated with each other making
our responses progressively relevant to the times and needs and based on the cherished

ideals of human relationships may be the answer.

KLrtKtNCtb
t
6

1.

Bhattacharya, N.L. ed., Susruta Samhita , Mysore: University of Mysore,

1973.

2. Chren, Mary Margaret, Landfeld, C. Seth, Murray, Thomas H. Doctors, drug

companies and gifts. J.A.M.A. -.India, 1990; 6 :641-6^4.

3. Das Gupta, S.M. Mercy killing, an analysis based on human rights, Proceedings
of the International

Conference on Healthy Policytethics and human values,

New Delhi: 1986, E-29.
4.

D'Silva, 3oe. Newstimes, Hyderabad, October 22, 1989.

5. Duggal, Ravi.

Exploding the population bomb myth, Medico-Friends Circle

bulletin , 1989, 152/153.
6.

Marsha

Goldsmith,

F.

Oregon

ti
pioneers "more
ethical" medicaid

coverage

with priority setting project. J.A.M.A. 1989; 262 : 176-177.
7.

Haring,

Bernard.

Medical

Ethics,

St.

Paul

Publications,

ed.,

Gabrielle L.

Jean, 1972.

8. .Holder,

Angela

Roddey.

Medical

malpractice law,

New York: John

Wiley

and Sons, 1975.
9.

1CSSR

ICMR study on Health for All - an alternative strategy, Pune:

Indian Institute of Education, 1981.
10. Jayadeva
1986.

Vidyalankara,

ed.,

Charaka Samhita ,

Delhi:

Motilal

Benarsidass,

11. Jindal, S.K. and Jindal, U.N. To tell or not to tell: professional practices
in the case of dying. Proceedings of the International Conference on Health
Policy: ethics and human values, New Delhi: 1986, E-20.

12.

Kane,

P.V.

History

of dharmasastras,

2nd ed, Pune:

Bhandarkar

Oriental

Research Institute, 1974.
13. McCarthy, Donald G., Moraczewski, Alberts. Moral responsibility ii n prolonging

life decisions, St. Louis: Pope John Centre, 1981.

Control of Fertility
Adapted from Dr. Ravi Duggaj)
,n

1800, both

underdeveloped
growth rate of 0.1/7%
By 1990, the

developed

world added,47.5%

a„d

developed

world added 13496

to its Population.

.»0Sroupscameback

After 1950, the

reversal has taken

world h.

to its Popula.

on level.

place.

Between 1800 and 1900, the
industrial
a-eierated, draining the wealth of
revolution in Europe
today’s
third
he countries of Europe and N
world (colonies)
America
became
PrOduced a massive spurt in
affluent.
population and then
jt stabilised.

There were also

other factors.
Ther e was disorganization
massive shifts
; t0 industrial areas.
Aether way of taking
Pressure 'from
Europe was the
Africa^'" niigratiOn t0 the t- -.tries
Zealand a
nd South
jr
It was ojt
a§e group wh0
the members of vorking
migrated.
"‘f today ’s industrialised

^XTsr’phic
P^se

world took over a
er a cent ury after i
its •
lnt° 'J0W ^rtility, why is t
it c
- ^.rial
—1 revolution, to

- - ■■

transit i

The escape route
by migration is

India,

,Countries with

settle there.

Jarge space do

not a vailable
to third world
nOt aJJow migration
of or

INFORMED

CON SENT

A number of questions were raised in the case reported:

(1)

Is explicit consent necessary

from a patient in critical condition but in full

possession of his senses, before undertaking any procedure on him?
(2)

the case as one requiring immediate surgery
refuse to operate on the sole ground that the patient had not given his explicit
Can the surgeon who diagnosed

consent for the operation?

(3)

If by the doctor's refusal

the surgery,

to undertake

the patient later dies,

what is the liability of the doctor?

The Kerala High Court observed that when a surgeon advances a
plea that
the patient did not give his consent for the
surgery, or the course of treatment
advised by him, the burden is on the surgeon to prove that the non-performance
as advised
of the surgery or the non-administration of the treatment was on account of the

refusal of the patient to give consent thereto.

This is especially so in a case of

a patient who submits to the doctor-, the absence of the consent must be made
out by the person alleging it.

A doctor is the best judge to decide whether or not an operation is necessary

when a patient is brought to him and if he decides that an operation is a must
tosave
the

the patient, which

jrnplied consent

of the

the operation must be performed

with

formality of
The formality
of an express consent
The

from

cannot wait,
patient.

the patientmight be dispensed with, having
the

regard to

patient and urgency of the operation, although

the critical condition of

the operation

might be

risky

to the knowledge of the doctor.

Section 88 of the Indian Penal Code gives complete protection to a doctor,
who knowing that a particular operation is likely to cause the death of the patient

and not intending

to cause death and in good faith, performs the operation with

the patient's consent, which may be express or implied.

If unfortunately, the patient

dies during or after the operation, the doctor is not liable.

If no criminal liability

is to be fastened, the operation must be performed in good faith and not intending
to cause death.
must be evidence
his duties.

In order to fasten a civil liability, in an action for damage, there

to show that the doctor

was negligent in the performance

Lf

r

Annexure 1

INDIA
:

Total population

818.8 millions (1988)

Major religions (1981)
Percentage

Religion

Number

Hindus

549,779,481

82.6Q

Muslims

75,512,439

11.35

Christians

16,165,447

2.43

Sikhs

13,078,146

1.96

Buddhists

4,718,796

0.71

Jains

3,206,038

0.48

Population under 5 (1988)

112,400,000

Population under 16 (1988)

319,300,000

Population annual growth rate

2.3 (1965-80); 2.2 (1980-87)

Population urbanised (1988)

27%

Annual growth rate of urban population

3.6% (1965-80); 4% (1980-87)

Annual number of births

26,446,000 (1988)

Annual number of deaths

3,940,000 (1988)

Crude death rate

21 (1960); 1 1 (1988)

Infant mortality rate

165 (1960);

Under 5 mortality rate

282 (1960); 149 (1988)

Percentage of children with low birth
weights

30% (1982-88)

Life expectancy in years, at birth

44 (1960); 58 (1988)

98 (1988)

Percentage of population with access
to safe water, 1985-87

Urban

76%

Rural

50%

Total

57%

T.B.

12 (1981);

DPT

31(1981); 73 (1988)

Polio

7(1981); 64 (1988)

Measles

- (1981); 44 (1988)

Tetanus

24 (1981);

Percentage of fully immunized
Children :

Pregnant women :

72 (1988)

58 (1988)

iin uin v^ornu./

*

300 (1987)

GNP per capita in US $

8 (1980-87)

Rate of inflation, %
Percentage of population below absolute
poverty line (1977-87)

Urban

40

Rural

51

1970

47 (male); 20 (female)

1985

47 (male); 29 (female)

Adult literacy rate, percentage

Total (1985)

43%

Primary school enrolment
ratio (gross)

80 (male); 40 (female)

1960
1986-88

:

113 (male);

81 (female)

Secondary school enrolment
ratio (gross)

1986-88

50 (male); 27 (female)

(Source: The State of World's Children, 1990
UNICEF,

Oxford University Press, mainly)

1^.

Palmer,

P.E.S.

The

epidemic

of

investigations,

international

Journal

Epidemiology , 1985; 19 : 359-365.

15. Radhakrishnan,
16.

S. Indian Philosophy, Delhi:

Oxford University Press, ' 1929.

Ramachandran, C.K. The total life-vision in ancient Indian Medicine,
Science of Life , 1986; 5 : 139-192.

17.

Ramachandra

Rao, ed., Encyclopaedia of Indian

Medicine, Bombay:

Book Prakashan, 1987.
18.

R amalingaswamy,

V.

Another

revolution

in

of

Medicine,

Ancient

Popular

Key note

address,
International seminar on recent trends in non-invasive organ imaging, 1986.

19.

Sarkar, Benoy Kumar. Indian Culture, Patna: I.B. Corporation, 1936; 2 : 80^

20.

Srinivasamurthy,
Mamatha

Shetty

R,
and

Somnath

Chatterji,

Raghavan,

Sriram,

T.G,

Parvatha

K.S. Informed consent for

drug

Vardhini,
trial: a

systematic study, NIMHANS Jou rnal, 1988: 6 : 195-149.
21.. Thairu, K, Manufacturers and users in joint endeavour, World Health
Forum,
1989; 10 : 23.
22.

Wadhwani, Y.K. Subtle bodies postulated in the classical
Journal of the L.P. Institute of Indology , 1976; 5 : 29-QO.

Samkhya

system,

MEDICAL ETHICS IN INDIA -• ANCIENT AND MODERN

DR. C.M. FRANCIS
COMMUNITY HEALTH CELL
560034
BANSALORE

SflNIEmS
1.

Introduction

2-

Informed consent

3.

Unethical

practices

advertisements

diagnostic

aids

drugs and pharmaceutica1s

4.

Right to health - health policy

demands of the few

versus

needs of the many

5.

Control of fertility

6.

Right to life - abortion

female foeticide

euthanasia
7.

AIH/AID/Surrogate mother

8.

Medical education

9.

Organ transplants

10. Terminally ill.
References
Annexures :

1.

India
2.

Informed consent

3.

Control of fertility

Infanticide

MEBlLCAL ETHICS IN INDIA - ANCI ENT AND MODERN

1.

INTRODUCTION
Ancient

with

a

Indian thoughts. philosophy and

rational synthesis, went on gathering

concepts.

Spiritua1

cultural history.
according

to

developed

itself

into

experience was the foundation

new

of

India's

Next to spirituality, dharma (ethical

conduct

one s

state) was the most

important

of

concept

Both are. unfortunately, on the decline.

Indian thought.
1 ■ 1 New

ethics j,

yenc es

With the coming of the Westerners, and especially during the
Imitation

colonial rule, changes in our behaviour became faster.
of

popu

what the rulers did and practised became more and more

lar.

This was especially so in Medicine with the supplanting of

the

Indian systems with the allopathic (modern) system of

But, there was also resistance to this wholesale copying

cine.
of

Westerners.

the

"Reverence
certain

for

doggedness

There

the past is a national trait.

of temperament, a stubborn loyalty

nothing in the long march of the ages.

to

the

is
lose
new

does

not

to

his

importing as much as possible of the new

into

temptations of the hour.. but holds

trad i tiona1 faith,

to

When confronted with

or sudden extensions of knowledge. the Indian

cu1ture
yield

Medi —

fast

a

the old.

Conservative liberalism is the secret of the success of

India's Culture and Civilization" (11)

Dr. Radhakrishnan, former President of India

1 - 2 Va 1 Lie systems
The value systems in India have been influenced by all the
religions, but mostly by Hinduism, the major religion (92.64% of
the population), contributing to the philosophy and ethics'of the

people of the country. The fundamental basis of ethics arises
from the Hindu belief that we are all part of the divine F-1 a ram at -rna_n; we have in each of us Atman, part o-f that E^^natman

The ultimate aim is for our Atman to coalesce with Paramertnian

or

fc^hman to become one.
According to the Vedas (400 B.C..
your neighbour as yourself is

thy

ii

to 1000 B.C.),

the call to love

because thy neighbour is in

very self and what separates you from him is

mere

truth

i1lusion

(maya)".

Closely allied to Hinduism are Jainism and Buddhism.
religions proclaim ^Ahimsa Paramo OJnarmal.

These

Most important of all

our actions is ahimsa, non-violence. Patanjali defined ahimsa as

Sacvatha Sarvada sarva^i^nam

ariabhid.roha" ,

a complete absence of ill-will to all beings.

Ayurveda is the ancient science of life.

ciples

It

lays down

of management in health and disease and the code of

of medicine as two fold; preservation of good health and

ing disease.
style;

con —

Charaka(10 > has described the objective

duct for the physician.

combat—

Ayurveda emphasised the need for healthy lift
and

cleanliness and purity, good diet, proper behaviouf,

mental and physical discipline.
be

pr in—

the

observed

Purity and cleanliness were to

< pure

in everything:

(clean food), dehasuddi

water),

aha '_a sudd i

(clean body), manasuddi (pure mind) and

.de_sasuddi (clear, envi ronmen t) .

Ayurveda

cal 1 s

upon

the physician to treat the

patient

a

as

who1e:
"Dividho laya±e yyadih

Nirdy<adva.m noBaJc3bhya_te"

1

Aswamedha parva of Mahabharata

(Diseases occur both physically and mentally and even though each

part might be dominant, they cannot be compartmentalised).
The

ancient Ayurvedic system treats man as a whole

mind and what is beyond mind.
Indian

Medicine,

body ,

The earliest protagonists of

such as Atreya, Kashyapa, Bhela,

Charaka

and

Susruta have based their writings on the foundations of spiritual

philosophy and ethics. But the one teacher of Ayurveda who estab—

lished the science on the foundation of spirituality and ethics

Ayurveda is the ancient science of life.
ciples

It lays down the

prin

of management in health and disease and the code of

con

duct for the physician.

Charaka(lO) has described the objective

was Vagbhata, the author of fistanga Hridaya (11).

Vagbhata says :

Su kart hah sarvabutanatn
tl^tah sarvah
h_*in £a na yina cBiarmat

thasmad dhamajjaro bhavet^
activities

(Al 1

of

man are directed to the

end

attaining

of

happiness, whereas happiness is never achieved without righteous
in

his

Samhita has elaborate code of conduct; the medical

pro

It

ness.

is

the bounden duty of man to be

righteous

action)Charaka

fession has to be motivated by compassion for living beings

(bhuta-daya)

( 12) -

Charaka's humanistic ideal becomes

in his advice to the physicians (10).
money

nor

"He who practices not for
1iving

for caprice but out of compassion for

(bhuta-daya) !• is the best among all physicians.
find

a conferor of religious blessings comparable to the

who

regards compassion for living beings

beings

Hard is it to

cian who snaps the snares of death for his patients.
cian

evident

as

physi—

The physi

the

highest

religion fulfils his mission (siddartah.) and obtains the highest
happiness".
2.

The problems are mainly
1)

those concerning the professional activities of the doctors
and related ones

those connected with social justice and equity„ including

(2)

the

use of sophisticated technology, experiments

on

human

beings and right to health. and
(3)

those related mainly to the beginning and end of life.

2.1.

Ii2EQB£O. consent
There is a general belief among the doctors in India

because of rampant

it is not possible to get 'informed consent'
illiteracy.

that

They believe that the patients are unable to make

reasoned choice because they cannot appreciate the intricacies of
Often

alternative medical treatment, procedures or drug trials.
a paternalistic view is taken:
Dr.

Srin ivasamurthy

"the doctor knows best".

and colleagues (14)

at

the

National

Institute of Mental Health and Neurosciences, Bangalore, conduct
ed

a

study into the relevance of

informed

consent.

(997.) of the subjects invited to participate in a drug

Almost all
trial

obtaining

gave

a

c lear

choice

whether

to

participate

or

not.

Patient's 1 eve 1 of understanding and decision-making related to
the

amount

and quality of information provided.

They

did

not

correlate with social, economic, educational or other background

characteristics.
Can the doctor withhold treatment,
consent'?
men t

'informed

Can a man refrain from benefitting from medical treat

and forfeit saving his life?

suicide?

if there is no

Will the doctor be

assisting

On the contrary, does not the patient have the right to

control what shall be done to his/her body?

What is the status of 'informed consent' when a patient is
admitted to the hospital in a critical condition but in full
possession of his/her senses?

the

Can the surgeon who diagnosed

condition requiring immediate surgery refrain from operating on
sole ground that the patient had not given

the

for the operation?

his/her

If the patient later dies, what is

consent
the

liability of the doctor?
An interesting case came up in the State of Kerala.

tien t

hospi ta1.
as

acute abdominal pain was admitted

with

the

Distric t

He was examined by the surgeon, who diagnosed the case

perforated appendix with general peritonitis. which

an immediate operation.
the

to

A pa

surgeon

required

But the operation was not performed by

and the patient died the next day.

The

relations

filed a petition in the court against the doctor personally and

against the Kerala Government vicariously.

The doctor's

defence

was that the patient did not give the consent; the operation

therefore was not done.

The court rejected this plea and granted

a decree against the doctor.

The decision was confirmed by the

Kerala High court in the appeal preferred by the doctor.
Two specialist Surgeons who were called as expert witnesses
stated that they would have operated on the patient without the
explicit consent.
Contrasting to the above is the view that every human

being

has a right to determine what shall be done with his or her own

body;

a surgeon who performs an operation without the

patient's

consent commits an assault for which he is liable (9) .
Indian

physicians

who are trained abroad or

have

imbibed

this principle find themselves in a conflicting situation.

What is the ancient teaching in such circumstances?

Chaara

ka advises the physician to take into confidence the close

rela

tives ,

the elders in the community and even the State officials 9

before

undertaking

patient.
In
vogue.

procedures which might end in death

the

of

The physician is then to proceed with the treatment
India j, ethics of trust has been and continues to

be

in

But more and more people are questioning the practice.

They want to make their decision especially in the light of

is happening in the West.

Ethics of trust based on

what

'goodness'

of

the doctor is slowly giving way to ethics of rights.
2.2.

UNETHICAL ADVERTISEMENTS
There

tors .

are instances of unethical advertisements

by

doc

These are frowned upon by their colleagues but little

action follows.

The Medical Council is to look into such matters

but because of technical f 1 aws j, the doctor often escapes.
Recently, advertisements by hospitals and diagnostic centres

are

coming up in a big way claiming that theirs is superior to oth
ers.

This is producing problems.

"It is totally unethical.

think any agency worth its name will not advertise in such a

I

manner".

Joe D'Silva, General Manager,

Imageads (4 >, Mr.

V ikram

Reddy, Creative Director, R.K. Swamy, says "If I were heading an
agency

I will not resort to such unhealthy advertising".

But it

is the general trend in the country in all commercial and Indus
trial

advertising.

Sue h

practices are

bound

to

affect

the

"health industry" also.
2.2. DIAGNOSTIC AIDS
There

is

a growing supermarket in

diagnostic

equipment.

Sophisticated equipment is bought at great expense of scarce

foreign exchange.

Most of the imaging equipment currently in use

in the various hospitals and diagnostic laboratories is excessive
when

re1 ated

to

the needs and the complexity

to

operate

and

problem with the purchase

equipment

from

maintain.
Yet

another

of

abroad has been the difficulty of servicing and maintenance.

trained

Doc tors

abroad in the specialities ask for

the

costly

requests.

But should not these specialities equipment be tern

pered

the

by

realities of the situation?

function for some time.

back-up service.

The

equipment

may

When they go out order, there is no

Net result is that the equipment lies idle

Is it ethical for the doctor to order for costly.

sophisti—

cated equipment, which is not likely to function, utilising

scarce foreign exchange?

Is it ethical for firms to supply these

items without back-up service?

This is a problem in most third

wor 1 d

countries.

Thai ru (15) suggests that

"an

code

ethical

should be agreed on by both (manufacturers and users) regarding
the sale of equipment”
2.3

DIa WS AND PHARMACEUTICALS

There is a huge proliferation of drugs in the Indian

market,

with more than 60,000 formulations.

They

tured by large, medium, small and tiny factories

are

manufac-

multinational

and national.

are many drugs in the Indian market which are

There

in other countries.
itself but

banned

There are drugs which were banned in India

continue to be marketed, after getting 'stay'

orders

from the courts.

Legal proceedings take years.

During this

period,

continue to prescirbe

hazardous

doc tors

these

drugs,

patients continue to take them and the firms continue to make

huge profits.
Many of the drugs in the market are spurious or of substa d
ard quality.

It has been eported that as a rule 20-30 percent of

the samples tested are substandard.
tured

by

firms

mu1tinationa1.

These are products manufac

irrespective of whether they

are

national

or

Government agencies take a long time to test the

samples and to announce the details of the substandard drugs.

Manufacturers are expected to give the indications.
indications, side effects and adverse effects.

contra

They often do so

but in such a way that it will not attract attention; the greater

the hazard. the smaller the print.

heal th

of the most distressing aspects of the present

" One

situation in India is the habit of doctors to overprescribe or to
poten—

prescribe glamorous and costly drugs with limited medical

It is also unfortunate that the drug producers try to push

tial .

fair

or

f ou 1 .

basic facts are more responsible for distortions

in

drug

into using their products by all means

doctors
These

If

and consumption than anything else.

profession

could be made to be more discriminating in

scribing

habits

there would be no market

for

medical

the

production

its

pre

irrational

and

unnecessary drugs (6).

The

drug

firms

do not generally follow

cirteria for drug promotion.

the

WHO

ethical

Gift giving j, almost universal.

raises many ethical issues as in other countries (2); the effects
are much more pronounced in a poor country.

In

the ancient days, the medicines were prepared under

the

personal supervision of the physician or by the families of the
patients.

There were strict guidelines for the collection of the

herbs and other raw materials and for the processes.

The medi

cines thus prepared were reliable for quality and purity.

3.1

RIBHI IS. H^LIH
ii

Everyone has the right to a standard of living ade

W the health

wk I 1-‘bwihU

«<•

hlrnseH

shd of I'ita ■family.

including -Food., clothing;, housing and medical care and

social

services"

human rights.

Article 25 of the Universal

necessary

dec 1aration

If health is a fundamental human right.

it becomes

the basic responsibi1ity of the State to protect and promote
health of all the people.

of

the

There has to be an irreducable minimum

of health care services to all.

It is both ethical and legal.

There is need to close the gap between the 'haves'

and ' have

nots', achieve more equitable distribution of health care re
sources

and

attain

a level of health for

al 1 .

Alma-Ata

The

Conference declared: "Governments have a responsibility for the
health of the people, which can be fulfilled only by adequate and
equitably distributed health and social measures".
The

right

to health brings on the

distributive

of

issue

justice to make available an acceptable and affordable care to
al 1 .

One

important aspect of such service is the

presence

of

qualified persons for health services, where such serivces are

not available.

Can the physician be compelled to provide service

to areas otherwise unable to obtain medical services?
compulsory rural service be prescribed?

Can a

The State and the insti—

tutions generally subsidise medical education.

Even if there is

no

opportuni ty,

subsidy,

the doctor has been provided

available to many.

not

an

But opposing questions arise.

owned by the people or the institution.

not

The doctor is

Can the

doc tor

be

deprived of the right to earn legitimately as much as he or she
can

and where he or she can?

Can a person be compelled

to

act

against his or her wish as long as no harm is done to the Socie
The consensus is that the doctor owes a duty to

ty?

the

serve

people in the areas where they are needed but the medical profes
in general, is not in favour of mandatory service.

sion .t

Hea1 th

is included in the Directive Principles of State

which is considered as the 'conscience'

tion .

policy,

of the Indian constitu

Article 39 of the constitution directs the State to ensure

health; article 47 requires the improvement of public health to
be among the primary duties of the State.

In pursuance of

these

articles the Government had issued a number of policy statements
The latest in the series is the National

and programmes.

Heal th

Policy (1982).
Health PeLiCY

3.2

There

can

be little objection to the

stated

nealth

policy of the Government of India but implementation has been
poor .

The allocation of resources to the health sector has

very sma11.

been

Often, the priorities are assigned based not on the

needs of the people but on what is fashionable.

Very little allocation is made to manage the infectious
diseases

such as tuberculosis and malaria which take

tol 1 with respect to mrobidity and mortality.

Kala-azar in the

the

maj or

Another example is

v illages of BiharjOrissa and West Bengal.

The

whole east coast of India is vulnerable to the resurgent attack

of

ka1a-azar

(a disease caused by

Leishmania

donovani).

The

efforts to prevent the disease and manage the outbreak have been

very poor.
Questions arise:

Who shall receive what health care?
What

resources

can be allocated, how

to

and

whom?

How do we set our priorities?
What is an acceptable form of health care?

Who should decide on health policy?
Many issues are being debated currently.

There is a

demand

for more equitable distribution of the benefits of medical knowl
But against it is the much more powerful force for the use

edge.

of sophisticated, spectacular and costly technology for the
benefit of the few.

Newer technology is skyrocketing the expenses for diagnostic
and therapeutic procedures.

People are direclty and indirectly
expensive

diagnosti

in f1uenced

to go through a whole array of

prodedures.

Patients are made to feel that, unless they go

through

possi b1e.
r ies j,

al 1 the sophisticated tests. a correct disgnosis is

not

There are wide networks of costly diagnostic laborato

aided and abetted by doctors. who often get kickbacks.
Patients are completely mystified by the adivce they get

from their physicians.

They shell out huge sums of money

tive to their earnings) which they can ill afford.

□num

squarely on the medical profession.

(rela-

The ethical

Does an individual have the right to buy expensive technolo
gy

Is

by the exclusion of others who share the same resources?

it right that the scarce resoruces of qualified and experienced
personnel, money including foreign exchange and materials be used

for the benefit of a few while the large majority of people are
not able to get even simple primary health care services?
All religions advocate the care of the poor and needy.
dec 1ared:

Christ

"When you have done this to the least

brothers, you have done it to me” .

you

taiisman-

a

"I will give

Gandhiji said:

becomes too much with you, apply the following test:

sei f

the

when

Whenever you are in doubt or

my

of

recal 1 the
your —

face

of the poorest and weakest man you have seen and ask

se 1 f ,

if the step you con templated is going to be of any use to

him.

Will

he

ancient thinking.
care

gain anything by it?".

This had

not

been

the

Physicians had been enjoined to give special

to the health needs of kings and those in

Kabir on Justice in Guru Granth Sahib said:

But

authority.

"The valiant fighter

is only he who,fights for justice to the poor".
The debate on distributive justice goes on:

Shal 1 the State

purchase ten renal dialysis machines (which will maintain the
life

of

a

few sick people) or employ

fifty

community

workers (to help 50,000 people achieve better health)?

heal th

Shall the

district hospital have two more specialist doctors or the primary

health centres have trained laboratory technicians who can spot
the malaria parasite?

Shall the hospital buy one lithotripter or

expand its programme for oral rehydration for children affected
The cake is small.

with diarrhoea?
Has

the

medical profession any ethical

influencing the health pollicy?

passive

How sha11 it be cut?

in

responsibi1ity

The doctors in India are often

spectators in the fight for social justice

and

against

discrimination in health care.
CONTROL OF FERTILITY
The

Government of India and the people of the

concerned with the increase in population.
is that of incentives and disincentives

country

are

One method proposed

incentives to those who

subject themselves to sterilization and disincentives to those
who are not willing to undergo steri1i1zation.
tion raises an ethical issue.

Such

Why should a third or fourth child

suffer from handicaps in education.. nutrition, etc - ,

son to other children?
the

country

in

compari—

The educational and other facilities in

especially so in

and

discrimina—

the

vi11ages

are

1imited.

Discrimination in favour of one works out to be discrimination

against another.
4.

fight to life
Artic 1e

dec 1ares:

3

of

the Universal declaration

"Everyone has the right to life..

of person".

of

human

liberty and security

Article 6 states: "Everyone has the right to

nition everywhere as a person before law"

rights

recog—

The International

covenant on Civil and Political Rights (1966), article 6

states:

"Every human being has the inherent right to life”.
other

These and
Who

is

ar©

two

declarations and affirmations raise the question:

this "person"

According

"human being"?
ancient

to

Samkhya philosophy,

there

ultimate principles in the universe: Rurusha (soul) and Prkriti,

(the

body).

Ln Ityal (16).

The soul is immutable Kutastha

and

imperishable

The soul or atman descends into the zygote, pro

duced from the union of the sperm and ovum, along with the

mind ,

which carried with it the influences of major actions done in
previous states of existence.
sperm and the ovum.

"Life starts with the union of the

Individual 1ity is reckoned from that moment.

It is at the moment of the sperm-ovum union that the transmigrating atman, Burusha (the individual) gets his material encrusta
lyen—

tion , as dictated by his previous karma", Dr. A. Ramaswamy
gar (personal communication).

Interventions

on the new human being should be such

maintain and improve the quality of life.

as

to

Therapeutic procedures

on the human embryo are licit. if there is respect

for life

and

integrity of the person (embryo/foetus) and should not involve
disproportionate
hea 1 ing

risk.

The procedures must be directed

towards

improvement in health and survival.

The growinq child in womb cannot be considered as an obj ect,
to be disposed off as thought fit by the mother or any other

tltet teppBRS i* an ihjdi-y is eaused to a foetus while in

Can damages be claimed?

uterus?

child

is

a

person.

If the answer is yes. then the

Can the life of this person

be

ended

by

procedures approved by others?
Most of the doctors in India do not wish to get entangled in

the debate.
4.1 ABORTI ON
The

Indian

law allows abortion.

"if

continuance

the

of

pregnancy would invo1ve a risk to the life of the pregnant woman
or grave injury to her physical or mental heal th"

Abortion was being practised earlier by many.
was

illegal5

it

was practised in a

passing of the Act made medical

with

certain

conditions,

clandestine

Because it

manner.

The

termination of pregnancy legal.

for safeguarding the

of

hea1 th

the

mother.
F rom

Apr i 1

1972, Indian doctors

zeal , abortions at woman's request.
invited

started

performing

with

Doctors advertised and

women to have abortions done at their clinics. The

Gov-

ernment saw it as one more method of population control.

Though abortion is legal, many find it 'immora 1'.
physicians
carrying
trimester,

But

most

in India do not see anything unethical or immora1
out medical termination of pregnancy within

the

first

for the'greater good' of the country in the light

the expanding population.

in

of

Abortion

is severely condemned in the

V^dicL?

Upanishadic.,

the later Euranic (old) and Brorit_i literature.
of

Paragraph 3 of the Code of Ethics of the Medical Council
India.says:

"I will maintain the utomst respect for human life

from the time of conception".
There is a conflict of the rights of two persons. the mother
and the growing foetus.

the

Has the mother the right to destroy

life of the child she is carrying in her womb?

Is the right

something akin to the possession of some material good, which can

disposed of as the mother wants.

without consideration of the

right of the unborn child?

4.2

SEX DETERMINAT ION AND FEMALE FOETICIDE

SEX F.RE-^ELECIION

There

are a number of methods available for sex

tion and sex selection.

determina-

Like traditional practices and mores.

they are pro—male and anti-female.
Some doctors in India have been carrying out procedures for

sex

determination.

It is perhaps peculiar to India

that

pre

natal determinatikon of sex is employed for rejection of a female
foetus.

If the test shows a female foetus, at the request of the

parents, the doctor performs an abortion.
thrive

in

Such abortion clinics

the country. in spite of public opinion

against

it.

Many physicians continue the selective abortion of female foetus
es, misusing prenatal tests for sex determination.

TheThgengeH&ra^i opcbn icon

the theuntbuRi t try ::

to " (ho $or f on bos taebo rti ion

merely because it is a female child is criminal and sinful".
there are quite a few persons who justify female

foeticide

in the Indian Society with its social custom of dowry.

And there

But,

are

of

advantage

quite a few physicians who would like to take

the possibility to make some quick financial gains.

The Government, though proclaiming against female foeticide.
does not seem to be too keen to effectively implement that poli
<=y-

India

has a sex ratio adverse to women

men ) according to the 1991 census.

(92? women

to

1000

The availability of sex pre-

selection and sex determination and female foeticide worsens

the

situation.

4.3

INFANT ICIDE
There is a growing tendency in many parts of the world to do

away with life.
compatible

with

if the newborn is detected with deformities 9
life but likely to put a great

family (eg., children with spina bifida).

India.

burden

on

the

This is much less in

The parents accept the children as part of their fate

or

But there is a growing number of persons who advocate
that the choice be left to the parents.
There are also instances where infanticide is resorted to

because it is a female child.
the newborn fema1e child.

But Guru Amar Dass,

There was practice to do away with

if the mother died during childbirth.

the third Guru of the Sikhs, opposed and

38

condemned the killing of daughters immediately after the death of
the mother.
In the Vedi,c_ times. there is no reference to infanticide of
born in wedlock j,

chiIdren

Manti advises the king

sure of the child born to unmarried women.
to

expo-

but there is a reference to the

or

award death sentence to him who kills a woman, a child

a

"Neither in this world nor in the next can any action

brahmana.

the injury of living beings be

to

resu1ts.

The conduct of persons who do not perform yr^vtas.
ceremonies)

(religious

good

of

productive

1eading

to

i11ing

are

tota11y

but whose minds ar not given

can lead to heaven" ( 13) .
The

great

maj ority

of physicians

in

India

against infanticide. even when the newborn has many defects at

birth.

KUIHANASIA

4.4

"Hasn't

according

a person the right to quit a life which.

to him or her. is not worth living?
implicit in the right to live?"

Is the right to die not

(3)

India does not allow suicide nor aiding and abetting sui
c ide.

But there have been questions raised.

in its fortysecond report stated:
to

inflict

The Law

Commission

"It is a monstrous procedure

further suffering on an individual who

has

already

slender,
found life so miserable, his chances of happiness so
that he has been willing to face pain and death to cease living".

The

controversy regarding punishment -For attempted

suicide

has hotted up with the recent judgements o-F the High Court and
Supreme Court.

While the High Court decision was to cut down the

provision o-F punishment. the Supreme Court has overruled it.
presen t

position is that attempted suicide (and aiding

The

suicide)

is punishable.

No documents allowing euthanasia in ancient times are

seen .

But there were advocates among the ancient physicians for aban
doning treatment(specific?), when the disease had reached a stage
from which recovery was considered unlikely.
Most

peop1e

reject positive euthanasia.

death in an active manner.
1ec tua1s.

Peop 1 e j,

bringing

by and large, accept suffering

process o-F dying.

about

The exceptions are among a few intel

their -Fate, resulting -From k.a_rr[i_a.
the

of

as

of

part

But there are many who favour

They also favour measures to relieve

the

constant agony. suffering and pain, even if these measures might

have a secondary deleterious effect on the length o-F life.
5.

AIH/AID/SURROGATE MOTHER

The desire to have children is a dominanit one. to be
■Fulfilled .

What

is to be done when there

are

impediments

to

having a child in the natural way and there is no way of overcom

ing sterility in one or the other partner?

way

One

out is adoption.

But many people

desire

to

According to

Charaka

Samhita 9

have

their own children.

What

do

the ancients say?

"the man without progeny is like a tree that yields no shade.
any

which has no branches. which bears no fruit and is devoid of
pleasing odour”.
expected

to

India's social structure required a son.

He is

He

provide support to the parents in old age.

is

also required to perform certain religious rites on the death of

the

parents.

A married woman is under social pressure

ceive soon after marriage.

con-

to

A sterile woman is considered inaus

picious.
Artificial insemination by Husband/Donor is practised fairly

widely.

cost

especially among the upper and middle classes. The

is high as also the failure rate.

The practice of surrogate

motherhood is extremely rare in India.

6.

ME£D I CAL EDUCATION

The process of training often determines the ethical
values

The

held by the physician and the profession.

emphasis

given to the teaching of medical ethics can affect the profes
siona1

behaviour

of the future physician.

In

general

today,

there is little emphasis on training in ethics and related sub

j ects.

There are a few exceptions but they do not constitute

even ten percent of the institutions in the Country.

Dealing with instructions to medical students, Charaka (7)
says:

*

Your action must be free from ego, vanity. worry,

agitation

of mind or envy; your actions must be caefully planned, with
concern

•for the patient and in keeping with

the

instruc—

tor' s advice.
*

Your

unceasing e-f-forts must. at all costs <Mr;va.tmana).

d i rec ted

towards

giving health to the

be

patients

suffering

(aturanam aroqya).
*

*

*

You

must

towards

your

patient,

whatever the provocation, even if it entails

risk

to your

life.

never harbour feelings of ill-will

shou1d

Never

you entertain thoughts lmajiasa£i.i.)

of

misconduc t

or thoughts o-f appropriating property that

not belong

to you.

Take

no

liquor, commit no sin. nor keep company

sexual

with

does

the

wicked.

*

Your

speech

must be soft,

pleasant,

virtuous,

truthful,

useful and moderate.
*

What you do must be appropriate to the place where you pract ice
do.

and the time. and you must be mindful

in whatever

you

house

Do not reveal to others what goes on in the patient's

*

ho 1 d .

*

Even when you are learned and proficient. do not show off.

Difficult it is to master the entirety of medical science; there
fore j,

one must be diligent in maintaining constant contact

with

this branch of learning.

According

the ancients. medical wisdom is

to

acquired

by

three methods:

(1)

study l^lhvaxssn^L!. earnest and continuous.

(2)

teaching

after examining the student and ascer
his

taining

imparting

character, ability j, health

1essons

concerning

life

in

and

interest

general,

and

medical

profession;, medical ethics and science of medicine. and
(3)

academic discussions £tat^.ijdYa“sambashal with colleagues and
fellow students. in order to enrich one's own knowledge.

to

of knowledge and to get rid of

doubts

to

new

methods

and

obtain

c1ari ty

deepen

one s

understanding and to learn

ideas, and to become skilled in expressing one's thoughts.
Medical ethics
Active learning is placed before teaching.
are among the broad subdivisions to be taught.
At the time of commencement. the student had to take an
oath .

But what was more interesting was that the

teacher

also

had to take an oath:

I

do

"When you on your part keep your vows and if

respond fully and impart all my

not

sha 1 1

(2)

become a sinner and my knowledge shall go fruitless."

major problem in the country today is the admission of

One

into "Capitation Fee Medical Colleges" based

students
paymen t
about

I

know1 edge,

a large sum by the student (or parent).

of

most1y

payment j,

to Rs. 30,00,000.

20 j, 00,000

Rs.

unaccounted,

upon

the

is

now

It

□n the

basis

is

admitted.

the student

sue h

of

Other

students !• even though they may be far more ’merited' academically
and otherwise are not admitted because they cannot afford to

the large amount.
to

Because the basis of admission is the capacity

prac —

pay the large amount to the management, many unhealthy
arise.

t ices

vitiated;

The whole environment becomes

teaching

pay

commercialised

and

institutions

are

and patient care in these

also affected.
Will medical ethics survive under such conditions?

TRANSPLANTS

7.

There is a big demand for organ transplants, especially

for kidneys.

These demands and the means of meeting the demands

raise ethical nightmares because of

often

unscrupulous

activi-

ties .
There is a small group of transplants where close relatives

donate

their

kidney.

This is possible because

of

the

strong

But the large majority of transplants are carried

family ties.

out on a commercial basis.
doctors

Some

in

kidney

There were unlimited number of kidney patients from

transplants.
the

goldmine

in India saw a potential

rich middle east.

Indian

in addition to the rich

They were prepared to pay.

patients•

Kidney transplant became a commercial

A new class of agents or organ procurers rose

proposition.

up.

The doctors involved were not bothered about the ethical issues
of robbing a kidney from an unsuspecting person.
It is often the illiterate people of the slums of Bombay,
Madras

and

other

places that "donate'

the

kidney.

even

But

knowledgable persons are also prepared to give away one kidney

because they are in desperate need for money.
In India, almost all kidney transplants were from
'donors'.
The

1 ive

There have been very few cadaveric transplants.

new

Act

passed by Parliament is

cadaveric transplantation.

It has defined

expected

to

favour

'brain death',

Whether live or cadaveric, organ transp1antation raises many
ethical issues.

8.

I^BMINALLY ILL
Physicians have been brought up to preserve life and

prevent death.

The ancient teaching has been that knowledge of

to

incurabi1ity

with—

of the disease should not make the physician

draw care or treatment.

As long as the patient breathes. it is

the duty of the physician to provide treatment Ltat/y^t p.ratikrl^

Ejar y_a yavae c hvasiti m an ava hJ. (12).

But there is also another

one should know when to stop treatment.

view:

quali—

Among the

ties that brought credit to the physician is the withdrawal of
treatment of one whose condition is definitely moribund lupekstianam RraKri^te^tlLLl. (7) .

may

The two apparently contradictory dictums

withdrawn and care to be given to the terminally i 1 1

be

to

probably mean that the heroic specific treatment was

to reduce

suffering.
The

present thinking is also in line with the above.

Pro

longing

life with the help of machines when there is no

chance

of recovery or in patients suffering with great pain and distress
because of incurable illness has been questioned more and more in

recent times.

If restoration of health is no longer possible and
extraordi-

death is imminent. the physician need not do anything

or

nary

necessary to relieve pain and suffering.
be

proper

and

These measures have

to

heroic to prolong living (dying) but it is

taken, even if they may incidently shorten life.
is expected to assist the patient in achieving

c ian

The

physi—

a

peacefu1

the

ancient

death .

8.ITO TOLL OR NQT TO TELL

According

to

Charaka and other physicians of

days j, the physician must be careful

in telling the patient about

the

of the incurable nature of

possi bi 11i ty

should not be told bluntly.

made

preferably

It

i11ness.

the

It is

It may shock the patient.

known to the patient's re1atives

qven

and

to

state officials (■fear of punishment j, should the patient die under
care!.)

his

Treatment of a heroic nature is to

undertaken

be

only with the consent of the relatives and elders.
In

much

modern days, doctors differ in their approach about how

and when to tell the truth to the patient, while caring for the
patient's

There are many conflicting considerations: the

dying.

right to know; the benefit to the patient; possible harm.

study conducted in the Postgraduate Institute

A

Research, Chand igarh, showed that

and

Education

of

69.27.

favoured telling the truth. while 30.87. did not

doc tors

in

telling the truth to the terminally ill patients (11).

of

the

doctors favoured involvement of the family

close relatives.

of

the

believe

Most

members

In view of the family structure and the

ties among the relatives in the Indian set-up,
obvious

Medical

and

closer

this aspect is

of

importance.

CONCL.US I ON

We have moved a long way from the precepts and practices of

the ancients.

This is true of ethics in general; the medical

profession is also affected to a lesser or greater extent by
the

c hanges.

Part of the change has been because of an

erosion

of the values cherished in olden times; part of it is due to
different

think ing,

influenced to some extent by

contact

with

science

and

technology.

We have been

situations

creating

to

which our ethical responses have been slow to develop or even
unable

to develop.

What is the way out?

Perhaps,

a

judicious

blending of the ancient with the modern, integrated with each
other

and

making our responses progressively relevant to
needs and based on the cherished ideals of

ships may be the answer.

human

the

times

relation

1.

Bhattacharya,

N.L. ed . , Stasrcrta Sam hi ta , Mysore:

University

of Mysore, 1973.
2.

Chren 9

Mary Margaret,

1andfe1d, C. Seth, Mur ray j,

Doctors, drug companies and gifts. J,A.M.A.

H.

Thomas

1990; 6

India,

-841-44.
3.

Das

Gupta, S.M. Mercy killilng., an analysis based

on

human

rights. Proceedings of the Int.ei:national Conference on Health
hallcYA. etfUcs and human, values.! New Delhi:

1986, E-29.

4.

Dz Silva, Joe. Newstimes., Hyderabad, October 22,

5.

Haring, Bernard.
Gabrielle L. Jean ,

6.

an alternative strate
1981 .

Jayadeva Vidyalankaras ed . j, Gharaka Samhita, Delhi: Motilal
Benarsidass <,

8.

J indal,

1986.

S. K. and Jindal

U.N.

To tell or not to tell:

fessional practices in the case of the dying.
the

lrrtern.ational

in

ethic, a

and.

1986, E-20 .

McCarthy, Donald G., Moraczewski, A1berts.

kiXitx

pro—

Proceedi j.gs of.

SODierence on Health. Policxs.

human values, New Delhi:

9.

ed . ,

1972.

Indian Institute of Education,

gy !• Pune:
7.

£t h i c: s, St. Paul Publ ic at ions

ICMR study on Health for All

ICSSR

1989.

Mfir.a 1 reseo nsi

erolpnaing. life dec: is ions , St. Louis:

Pope

John

Delhi: Oxford University

10. Radhakrishnan, S. Indian
Press,

1929.

1 1 . Ramachandran,

The total

C. K.

Medicine, Ancient Science of Life^

ed . >4

Rao y

12. Ramachandra

13. Sarkar, Benoy Kumar,

139-142.

1986; 5 :

En£y£l^!Eae.dia.

Bombay: Popular Book Prakashan,

Indian

1i fe-vision in ancient

Ql

Ind ian

Med i ci n e„

1987.

Indian Cyjturg:, Patna:

I.B. Corporation,

1936; 2 s 804
14. Srinivasamurthy, R, Somnath Chatterji !• Sri ram, T.G,
Vardhiniy Mamatha Shetty and Raghavan, K. S.

Parvatha

Informed consent

for drug trial: a systematic study, NIMHBhi..0a„ 1„,

1988:

6

:145-149.
15.

Thairu,

K,

Manufacturers and users in joint endeavour,

Health Forurn ,

16. Wadhwani,
Samkhya

1989;

Y. K.

10 : 23.

Subtle bodies postulated in

system, JourriM

1976; 5 : 29-40

No r 1 d.

±_he LJD

Institute

the

classical

2.±

I.ndulg.g.y,

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••*. U-

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•:»

- •

CODE OF MEDICAL <ETHICS
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' (Approved by the Central .Government u/s 33 of the
• Indian Medical CouncilAct, ’1956, - Vide their
letter No. F. 17-64 MPT, dhted 23rd October, 197C)

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MEDICAL COUNCIL OF INDIA ■V
‘ .

Aiwan - e - Ghalib Maxg'^Z 7 ~
Kotla Road
New Delbi-110002 - \ . r: ' '
■

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■

MEDICAL

COUNCIL

OF INDIA

CODE OF MEDICAL ETHICS
DECLARATION
Al the time of registration, each applicant shall be given a copy of tne fo'iav.-jre
declaration by the Registrar concerned and shall read and agree :o abide by the same :
1. I solemnly pledge myself to consecrate rm life 10 the servi.’? of humanity.

2. Even under threat, I will not use my me dice: ;:r,ov‘:dg, c?r.tra“> :? ih<- ia»v;
of humanity.
'
3. I will maintain the utmost rc-pcct lor human iif* fr?m »he v.me of crr.cemior.
4. 1 will not permit considerations of religion, nat.onahty race pat- peliiic; cr
social standing to intervene between my duty and r.y patient.
5. 1 will practise my profession with conscience and cigtnty.
6. The health of my patient will be my first considerat.on.
7. I will respect the secrets which, are confided in me.
8. I will give to my teachers the respect and gratitude which is tneir cue. I
9. I will maintain by all means in my power, the honour and noble tradition- ci’
medical profession.
10. My colleagues will be my brothers.
1 make these promises solemnly, freely and upon m;- honour.
CODE
GENERAL PRLNCIPLES

Character of the Physician
The prime object of the medical profession is to render service to pumanity;
. -reward of financial gain is a subordinate consideration. Who-so-ever chooses this
profession, assumes the obligation to conduct himself in accord with its ideals. “A r
1.

1
physician should be an upright man, instructed in the art of healings.” He must keep
himself pure in character and be diligent in caring for the sick. He should be modesty
sober, patient, prompt to do his whole duty whithout anxiety; pious without going so far
as superstition conducting himself with propriety in his profession and in all the actions
of his life.
2.

The Physician’s Responsibility

The principle objective of the medical profess on is to render sendee to humanity
with full respect for the dignity of man. Physicians should merit the confidence of
patients entrusted to their care, rendering to each a full measure of service and devotion.
Physician should try continuously to improve medical knowledge and skill and should
•make available to their patients and colleagues the benefits of their professional attainme pnysictan should practice methods of healing founded on scientific basis
ana shourd net associate professionally with anyone who violates this principle. The
honoured ideals of-he medical profession imply that the responsibilities of the physician
extend no: only to individuals but also to society.
3.

.’tdvcrtisicu

Sulicitati-'n of patients directly or indirectly, by a physician, by groups of
physicians or by institutions or organisations is ur.nhical. A physician shall no: make
use of or aid or permit others to make use of him «or his name) as subject of any form or
idvcnising or puoiicitv tiirough lay ch..:mels either alone or in conjuctioa
::\;r.r.cr
' uh ota.’-s wrich snail be of such a character is to invite attention to him or to ais
y :-fc£Mc:...i position, kill, qualification, achievements, attainments, specialities, aproint-c:at:?ns. atnliatior.s or honours and or of such character as would Ordinaniy
is seif aggrnr.disemicnt nor shall he give to any person who-so-ever. whether
ior com*'ansa:ion or other.vnc. any approval, recommendation, endorsement, certificate
rerort -r statement with respect of any drug, medicine, no st erm remedy, surgical, or
therauevtic article, apparatus or appliance or any commercial product or article wit.t
respect of any property, quality or use thereof or any test demonstration or trial thereof,
for use in connection with his name, signature, or photograph in any form or manner of
advertising through lay channels nor shall be boast of cases, operations cures or remedies
or permi; the publication of report thereof through lay channels. A medical practitioner
is permitted a fprmal announcement in press regarding the following :

(1)

On surting practice.

(2)

On change of type of practice.

(3)

On changing address.

14)

On temporary absence from duty.

? 5)

On resumption of practice.

(6)

On succeeding to another practice.

3
Payment of Professional Services
The ethical physician, engaged in the practice of medicine, limits the sources of his
income received from professional activities to services rendered to the patient.
Remunerations received for such sendees should be in the form and amount specifically
announced to the patient at the time the service is rendered. It is unethical to enter
into a contract of “no cure no payment”.

-■4.

5.

Patent and Copy Rights
A physician may patent surgical instruments, appliances and medicine or copy
right publications methods and procedure. The use of such patents or copyright or
the receipt of remuneration from them which retards or inhibits research or restrict
the benefits derivable therefrom are unethical.

I
Running an Open Shop (Dispensing of Drugs and Appliances by Physicians)
A physician should not run an open shop for sale of medicine for dispensing pres
criptions prescribed by doctors other than himself or for sale of medical or surgicil
appliances. It is not unethical for a physician to prescribe or supply drugs, remedies or
appliances as long as there is no exploitation of the patient.
6.

7.

i •

Rebates and Commission
A physician shall not give, solicit, or receive nor shall he oiler to give, solicit or
receive, any gift gratuity, commission or bonus in consideration of or in return for the
referring, recommending or procuring of any patient for medical, surgical or other
treatment. A physician shall not directly or by any subterfuge participate in or by a
party to the act of division, transference, assignment, sub-ordination, rebating, splitting
or refunding of any fee for medical, surgical or other treatment.
The provisions of this para shall apply with equal force to the referring, recom
mending or procuring by a physician or any person, specimen or material for diagnostic,
or other study or work. Nothing in this section, however, shall prohibit payment of
salaries by a qualified physician to other duly qualified person rendering medical care
under his supervision.
8.

Secret Remedies
The prescriptions or dispensing by a physician of secret medicine or other secret
jemedial agents of which he does not know the composition, or the manufacture or
-promotion of their use is unethical.

9.

. Evasion of Legal Restrictions
The physician will observe the laws of the country in regulating the practice of
medicine and will not assist others to evade such laws. He should be cooperative in

7

4

observance and enforcement of sanitary laws and regulations in the interest of public
health. A physician should observe the prov ’.sions of the State Acts like Drugs Act,
Pharmacy Act, Poisonous and Dangerous Drugs Act and such other Acts, Rules, •
Regulations made by the Central Govt./State Govts, or local Administrative Bodies for
protection and promotion of public health.

DUTIES OF PHYSICIANS TO*THEIR PATIENTS
Obligations to the Sick
Though a physician is not bound to treat each and every one asking his services
except in emergencies for the sake of human.ty and the noble traditions of the profession.
i.e should not only be ever ready to respond to lite calls of the sick and tne injured, bur
s.’.OwId be mindful of the high character of h:s mission arx the responsibility he incurs in
t?.e discharge of his professional duties. Ir. his ministrations, he should never torget
tna: the health and the lives of those entrusted to ?.is care depend on his skill and
attention. .A physician should endeavour l add to the comfort of the sick by making his
\ .sits a: the hour indicated to the patients.
11-.

Patience Delicacy and Secrecy
Patience and delicacy should charac.erize the physician. Confidences concerning
individual or domestic life entrusted by patients to a physician and defects in the dis
position o: character of patients observed during medical attendance should never be
revealed unless their revelation is required b} the laws of the State. Sometimes, however,
phvs cian must determine whether his duty to society requires him tn employ know
ledge. obtained through confidences to i.im as a physician, to protect a healthy person
azains: a communicable disease to v.hich he is about to be exposed. In such instance,
the physician should act as he would desire another to’act toward one of his own family
ir. like circumstances.

i:.

Prognosis
Tne physician should neither exaggerate nor minimize the gravity of a patient’s
condition. He should assure himself that the patient, his relatives or his responsible
friends have such knowledge of the patient’s condition as will serve the best interests of
the patient and the family.
12.

The Patient Must not be Neglected
A physician is free to choose whom he will serve. He should, however, respond to
any request for his assistance in an emergency or whenever temperate public opinion
expects the service. Once having undertaken a case, the physician should not neglect
the patient, nor should he withdraw from the case without giving notice to the patient^
13.

5

his relatives or his responsible friends sufficiently long in advance of his withdraVallo
allow them to secure another medical attendant. No provisionally or fully registered
medical practitioner shall wilfully commit an act of negligence that may deprive hH
-patient or patients from necessary medical care.

DUTIES TO THE PHYSICIAN TO THE PROFESSION AT LARGE
14.

Upholding the Honour of the Profession
A physician is expected to uphold the dignity and honour of his profession.

15.

Membership in Medical Society
For the advancement of his profession, a physician should affiliate with medical
societies and contribute his time, energy and means so that these societies may represent
the ideals of the profession.
16.

Safeguarding the Profession
admissio: to it
Every physician should aid in safeguarding the profession against admissiori
of those who arc deficient in moral character or education. Physician should not ednploy
in connection with his professional practice ;.ny attendant who is neither registered nor
enlisted under the Mesicai Acts in force ar.u should not permit such persons to attcnc.
treat or perform operations upon patients in respect of matters regarding nrcfcisicna.
j
discretion or skill as it is dangerous to nuriic health.
Exposure of Unethical Conduct
A physician should expose, without fear or favour, incompetent or corrupt,
dishonest or unethical conduct on the part of members of the profession. Questions o;
such conduct should be considered, first before proper medical tribunals in executive
sessions or by special or duly appointed committees on ethical relations, provided such
a course is possible and provided also that the law is no: hampered thereby, if doubt
should arise as to the legality of the pbysian ’s conduct, the situation under investigation
may be placed before officers of the law, and the physician investigators may take the
necessary steps to enlist the interest of the proper authority.

17

PROFESSIONAL SERVICES OF PHYSICIANS TO EACH OTHER
IS.

Dependence of Physicians on each other
There is no rule that a physician should not charge another physician forjhis service,

should cheerfully and without recompense give his professional services to physicians or

I
6

his dependants if they’ are in his vicinity.
• bs'isri:.'. 19- ^Compensation for Expenses

i

; - STfSfd £ycSiCir

l0WheJT phSX

should

rCim-

duties

of physician

in consultation
I

-0.. Consultation shnul^ be Encouraged
In case ot serious illness, especially in doubtful
or cifhcult conditions the physician
should request consultation.
21.

Consultation for Patient’s Benefit

responsible friend.

“ n.^mo^ o. his family or

’

Punctuality in Consultation
Utmost punctuality should be observed by

a physician in meeting for consultation.

23.

Conduct in Consultation
in consultations, no insmccrcty. rivniry or envy should b~ ir^Hcd in AlHirespect snould be observed towards the phvsHan ir -har^ nf th
n°u Stalcnisnt
or remark be made, which would impair the confidence bros r
no discussion should be carried on in the prcs-nc- o'r the nabemth‘S PUrP°SC
prvs.ncv o. the patient or ms representatives.
24.

Statement to Patient after Consultation
<a) All statements of the case to the mrienf nr hiplace in the presence of all the physicians consume e\cZ

“ ■he
25.

“ «•sm s:

Treatment after Consultation
No decision should restrain the attending physician from

making such subsequent.

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consultation, re^nTfoX^^iaUo ’tsXw'S

may require, but at the next
The
same privilege, with its
obligations, belongs to the consultant when sent for in
during the absence
an-emergency
of attending physician. The attending physician
any time for the
may
prescribe
at
patient, the consultant only in case of emergency.

Z

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26.

Consultant not to take Charge of the Case
When a physician has been called as a consultant nor,■
exceptional circumstances would justify that consultant tali- cfaX/oftamust not do so merely on the solicitation of the patient or fri-nds

nicst

Hl-

f9- «

27.

Patients Referred to Specialists
When a patient is referred
to a specialist by the attending phystetan. a states c
tile case should be given tto tne specuhst. who should communicate ni. eotntor J
writing in a closed cover direct
— t to the amending physician.

DUT.ES OF PHYSICIAN .X CASES OF IN'raFEIiENCC
28.

Appointment of Substitute
Whenever a physician requests another physician to att-r ’* bi- nnri , i
temporary absence from his practice, professional cour^ ^uir-s t ' '

■

*

suc.i appointment if consistant with his other duties The phv---h- ' . ‘ 3CC'ptanc'
jtn appointment should give the utmost considerat.on to tm int^

29.

Visiting another Physician’s Case

except ma case of emergency when he should communicate to h-F
c.rcumstances under which the patient was seen and treatm^t

30.

L

“‘H’
S 4

official position to see and
to the physician in attendance
officer should avoid remarks-

<

i=

Engagement for an Obstetric Case
•If. a physician agrees to attend a woman during her con6Een;eati he mus: do

8

Inability to do so on an excuse of any other engagement is not tenable except when he
is already engaged on a similar or other serious case. When a physician who has been
engaged to attend an obstetric case is absent and another is sent for and delivery
accomplished, the acting physician is entitled to his professional fees, but should secure
the patient’s consent to resign on the arrival of the physician engaged.
DUTIES OF PHYSICIAN TO THE PUBLIC
Physicians as Citizens
Physic:ans. as good Citizens, possessed of special training should advise concerning
the : caith of me community wherein they dwell. They should bear their part in
enforcing the laws of :he community ano in sustaining the institutions that advance the
ntercsts of hunv.ir.ity. They should operate especially with the proper authorities in the
31.

*0 ♦

aurnin: trauon of similar-- :av, 5 and regulations.
fl

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32.

Public Health
Phvsiciar.s. especiai'.y those engaged in public health won:, should enlighten the
public concerning uuarcr.tmc regulations and measures tor the prevention of epidemic
■ire c^mmumcaoie discuss. At ail times the physician should notify the constituted public
■r.iuiom:-;: -fever ease of ccmmunuabl* disease under his care, in accordance
vitr. th.
rules r.r.a regulations of the ’.-.enith authorities. When an epidemic
-rcv./.C. ;t -v.'Sicmn must ccmm.uc his labour without regard to the risk to his
•wn

c.iit*..

33.

b.armacists

Physicians 5houiG rccc-gr.izc and promote the practice oi pharmacy as a prolession
and nouid recoanisc -.h: cooperation oi the pharmacist in education of the public
concerning the practice oi ethical and scientific medicine.

DISCIPLINARY ACTION

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1
The Medical Council of India desires to bring to the notice of the registered
medical practioners the following statement upon offences and form of professional
misconduct which mav be brought before the appropriate Medical Council for discipli
nary action in view of the authority coferred upon the Medical Council of India and/or
State Medical Councils as provided under Indian Medical Council Act, 1956, or State
Medical Councils Acts as may be subsequently amended.

2. ‘•The appropriate Medical Council may award such punishment as deemed necessary
or may direct the removal altogether or for a specified period from the Register, the name
I

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9

I

of any registered practioner who has been convicted of any such offence as implies in
the opinion of the Medical Council of India and/or State Medical Councils, a defect of
character or who after an enquiry at which opportunity has been given to such registered
practitioner to be heard in person or by pleader, has been held by the appropriate
Medical Council to have been guilty of serious professional misconduct. The appropriate
Medical Council may also direct that any name so removed shall be restored.

It must be clearly understood that the instances of offences and of professional
3.
misconduct which are given do not constitute and are not intended to constitute a
complete list of the infamous acts which may be punished by erasure from the Register,
and that by issuing this notice the Medical Council of India and or State Meiiicai
Councils are in no way precluded from considering and dealing with any fori'.! o.
professional misconduct on the part of a registered pr’attiiiorter. Circumstance.’ ma;
and do arise from time to time ir. relation to which there may occur auesnek » c.
professional misconduct which do not come witnin any of these categories. L.vcry car:
should be taken that the code is not violated in ietur or spin:. In such instance. as in. ai
others, the Medical Council of India and or State Meaica’ Councils have to consider an
decide upon tne facts brought before tiic Medical Council of India and or Stau Mcdica
Councils.
LIST
Adultery or Improper Conduct or Association with a Patient
Any medical practitioner, who abuses, his professional position by comn'./.tin:
adultery cr improper conduct with a patient or by maintaining an improper a et;; .:or
with a patient, is liable for disciplincry action as provided under the Indian Mccicai
Council Act, 1956 and/or State Medical Council Acts, as may be subsequently umenued.
1.

Conviction by Court of Law for ofTcnces involving moral turptituJe.

Professional Certificates, Reports and other Documents
Registered practioners are in certain cases bound by law to give, or may from time
be called upon or requested to give certificates, notification, reports and other documents
of kindred character signed by them in their professional capacity for subsequent use in
the courts of justice or for administrative purposes etc.
3.

(i) Such documents include among other certificates, notifications reports(a) Under the acts relating to birth, death or disposal of the dead.
(b) Under the Acts relating to Lunacy and Mental Deficiency and 1 e rules
made thereunder.
(c) Under the Caccination Acts and the regulations made thereunder.

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10
(d) Under the factory Acts and the regulations made thereunder.
(e) Under the Education Acts.
(f) Under the Public Health Acts and the order made thereunder.
(g) Under the Workmen ’s Compensation Act.
(h)
(i)
(j)
(k)
11)

Under the Acts and order relating to the notification of infectious diseases.
Under the Employee’s State Insurance Act.
In connection with sick benefit insurance and friendly societies.
Under the Merchant Shipping Act.

For procuring the issuing of passports.

(m) For excusing att^d^r.ce in courts of Justice, in public services, in public
offices or in ordinary employments.
(n) In connection with rural and Military matters.
<o‘ In connection with matters under the control of Ministry’ of the pensions.
(ii » Any registered practioncr who shall be shown to have signed or given under
his name and authority and such certificate, notification, report or document of a kindred character which is untrue, misleading or improper relating jo the several matters
above t nccincd or otherwise, is liable to have h:s name erased from the Register.
(iii' \ Registered medical practitioner shall maintain a Register of Medical
crime;;:.-s giving :uii details of certificates issued. When issuing a medical certificate
. ■•ayf •ntcr the indcntification marks of the patient and keep a copy of the certificate.
D<» not emit to note down the signature or thumb-mark, address and identification
marhs the patient on the medical certificates or report.

Contravening the provision of the Drugs Act and regulations made thereunder.
5.
Seiling Schedule poison to the public under the cover of his own qualification
e?.cepi to his patient.
6.
Performing or enabling unqualified person to perform an abonion or any illegal
operation for which there is no medical, surgical or psychological indication.
A physician should not issue certificates of efficiency in modem medicine to
unqualified or non-medical person.

(Note : The foregoing does not apply so as to restrict the proper training and
instruction of bonafied students, legitimate employees of doctors, midwives,
dispensers, surgical attendants, or skilled mechanical and technical assistants under
the personal supervision of physicians).

■'..iO. --U?

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11
8.
A physician should not contribute to the lay press articles and give interviews
regarding diseases and treatments which may have the effect of advertising himself
or soliciting practice ; but it is open to him to write to the lay press under his own name
on matters of public health hygienic living or to deliver public lectures, give talks on the
radio broadcast for the same purpose and send announcement of the same to the
lay press.
9.
An institution run by a physician for a particular purpose such as a maternity
home, a sanatorium, a house for the crippled or the blind, etc. may be advertised in the
lay press, but such advertisements should not contain anything more than the name of
the institution, type of patients admitted, facilities offered and the residential fees.
Name of either the superintendent or the doctor attending should not appear in the
advertisement.
*
10. It is improper for a physician to use an unusually large signboard and write on it
anything other than his name, qualifications obtained from a University or a statutory
body, titles and name of his speciality. The name should be the contents of his
prescription papers. It is improper to affix a sigh-board on a chemist ’s shop or in places
where he docs not reside or work.
,
11. Do not disclose the secrets of a patient t’.iat have been learnt in the exercise of
your profession. Those may be disclosed or.lv in a Court of Law under orders of the
presiding jucdc.
12. Refusing on religious grounds alone to give assistance in our conduct of sterility,
birth control, craniotomies on living children, and therapeutic abortions when there is
medical indication ; unless the medical practioner feels himself herself inccmpetebt
to do so.

'

ifc,
13.
Before performing an operation in wriiting the consent from the husband or wife.
parent or guardian in the case of a minor, or the patient himself as the case may be.
In an operation which may result in sterility the consent of both husband and wife
is needed.

I

14. Do not publish photographs or case reports of your patients in any medical or
other journal in a manner by which their identity could be made out without their
permission. Should the identity be not disclosed his consent is not needed.
15. If you are running a nursing home and if you employ assisunts to help you. the
ultimate reponsibility rests on you.
i

16.

No physician must exhibit publically the scale of fees.
'•

■

— .

But there is not objection.

12
♦r

lo the same being put in the physicians* consulting or wailing room.
.17.
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i

No physician shall use teats or agents for procuring patients.
•

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Do not claim to be a specialist unless you have put in a good few years of study
.and experience or a special qualification in that branch. Once you say you are one, do
net undertake work outside year speciality even for your friends.

)

• I

Ferm of Certificate Recommended for Lr’’ c or Extension of Communication of Leave
I

i

S.-caature of applicant
or ihum’n impression..

To be filled r bv the *.ppiicant iu the presence cf the Government
Me.rca; /xr.ezutr’. or Medical Pructior.er.
alte- careful examination

I.

whose signature is given

of the case hereby that
ab^ve is suficriag rorr.

cf abser.ee from duty cf

1

and I consider that a period
i

......................................with effect from

i> absolute y necessary for the restoration of his health.
Date

Signature of Medical Attendant

Note :—The nature and probable duration of the ilir.ess should also be specified.
This certificate must be accompaincd by a brief resume of the case giving
the nature of the iilnes:. its symptoms, causes and duration.

J

(Approved by the Central Governu.-.-it u s 33 (m) of the Indian Medical Council
Act, 1956, vide their letter No. E. 17-4'64-MPT, dated 23-10-70)

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ST JOHN’S MEDICAL COLLEGE
DEPT OF FORENSIC MEDICINE

•

MNAMS - GP COURSE

• -

SALIENT FEATURES OF MEDICO<£GAL PROBLEMS AND
RESPONSIBILITIES INCLUDING C ERTI FI C4TI ON 4ND
COURT EVIDENCE;

For peaceful and healthy living ever/ society needs some laws
and rules.
Generally accepted ways of behaviour and of material dealing
are put down as_ 1----laws --------‘
and __1
rules.
—.
Public has to obey the edicts of general
law.
Doctors as members of the society observe these and have further to
abide by certain laws specially made for the profession^
These medical laws
are made in the interest of the- fLutilix health.
r_‘_'
Certain patterns of hnhawi nyr
is orescribed for the doctors by the elite of the profession,
These co-mma/vds
and suggestions are included in the law and ethics for doctors.
Medical law, broadly speaking has two major aspects.
The first
is embodied in Forensic Medicine which is concerned with the application of
medical knowledge to the purposes of law.
The second part of the medical law
is medical jurisprudence which is concerned with the stating and solution of
problems arising out of legal rights, powers, previlages, duties and obligations
of medical practitioners.
There is hardly a book in India which specifically attempts to
deal with the second part.
Since in depend*.-, nee the general public has fast become law conscious
and is more readily prepared to go to a court of la w to assert its rights and
previleges.
Added to the second part of medical law are the medical ethics and
medical etiquette which are the guiding rules of good conduct and are adopted
by the General Assembly of World Medical Association as Code of Ethics.
Medical ethics deals with the moral principles which should guide members of
the medical profession in their dealings with each other, with their patients
and the state.
Medical etiquette deals with the conventional laws of courtesy
observed among the members of the medical profession.
As the principle purpose of the Medical Practitioner is to render
service to the suffering humanity, he invites the confidence of these when
ho treats and advises.
To deserve the full measure of his pationtfe confidence,
hs should strive to conduct himself in a disciplined manner.
Etiquette as ]regards
‘ colleagues
_
is an elementary rule of ethics
that a doctor must not entice away patients from his colleagues and tha:
that
he ought to behave towards his colleagues as he would have them- behave
towards him.
In short medical profession is governed by legislat ujc and also
by code of ethics and etiqueitte.
These will pre^jent them from transgressing

•

2 :

Forensic Medicine deals almost entirely with crimes
„
_.
/ ------- ----------- against the
person in which medical examination and evidence are
It is mostly
are required.
required.
an exercise of common sense corlined with the application of experience
already required in the study of the branches of medicine.
Its aim is to find
out the truth.
The peculiar field of activity is judicial investigations both
Livil and Criminal. The? medical evidence itself docs not prove the case of
prosecution.
It only corroborates the evidence of eye-witness.
All medical
work is of a responsible character especially the medico-legal work such as
issuing certificates of lunacy, ill health, accident etc.
In all cases
crime involving the person as in homicide, suicide, assault, sexual offences,
traffic accidents, poisoning etc., the help of the medical practitioner is
sought by the police.
In all such cases the doctor has to appear as an
expert witness in a court of labJ.
Often the doctor is the chief source of
His effective use in the
evidence upon which legal decisions are made.
administration of justice is an absolute necessity for the peaceful and
orderly society.
In cases of sudden death the authorities will depend mostly or
completely on medical evidence in establishing the cause of death and in case
of accidents to determine the blame.
The doctor like any other citizen owes a duty to the cause of justice
and he should assist the court in the administration of justice regardless
of oersonal inconvenience and this includes the obligation to testify in any
legal proceedings when called upon to do so.
A doctor may be called to testify

D as an ordinary witness who saw something happened,
2) as a medical Practitioner who treated the patient,
3) as an expert called in. to give his opinion on the matter of medical science.
In the first two it is his duty and obligation to testify.
he may refuse the request.

in the last condition

1)

IP he feels reluctant to under go what he fears will be an ordeal,

2)

If he. ,feels
that he is r,ot sufficiently qualified to testify with any
.
conviction in that particular case

3)

If he feels that the cannot spare the time to
prepare properly or to
make long appearances in the court.

A properly prepared physician often finds his court room experienced,
educational and not as traumatic as he had anticipated.

fear °f mercilsss crOss examination, harassment,
even rerZii
even recall and public display of unfavourable previous episodes in the
medical practitioners personal life or professional career.
Doctors should not become partisans.
Once a theory is embraced, it
is °nly human nature to eagerly search for facts which support that theory
nd reject those that support some other
The attitude of the
other theory.
theory.
scientific witness should be the same whether he is called in by the
prosecution or by the defence,
He should not concern with the previous
character of the j----accused or with other evidences.
He should not be influenced
by sympathy or antipathy,.
The doctor must be honest for confidence is
inspired by honesty and success depends on confidence.

s 3 s

It is advisable that the doctor should learn to look from the medico
legal stand point upon such of his cases as are likely to become the subject
master of judicial investigation.
He should acquire the habit of making
a careful note of all the faces observed by him.
Vagueness and theory have
no Place in Forensic Medicine.
He should examine the facts which come t o
his knowledge in his special capacity, draw his conclusions logically and
correctly after a detailed consideration of the pros and cons of the case
and indicate to-the court that interpretation along with the ground on which
it is based.
The court has no special knowledge.
It relies on witness from an
opinion and expects him to assist it by special knowledge and experience.
In every case there is an element of uncertainty and absolute proof is a
No possibility is wholly inadmissible in
rarity in any medical problem.
Doctors should bear in mind the essential difference
medical experience.
between probability and proof.
They should be reasonable in their opinions
and should not overstate the likelihood of a relationship between cause and
effect •
As the general public is fast becoming law conscious and the doctors are
being sued from time to time in a court of law for their acts of commission and
omission, the medical men should have certain knowledge of various laws or
acts concerning the medical profession, drugs, public health etc and alio
certain acts of general application which may be of use to medical men.
■Acts concerned with Medical Professions
Indian Medical Degree Act
Indian Medical Council Act
Indian Nursing Council Act
Hospital&Nursing Home Act
Indian Lunacy Act
Pharmacy Act
Public Health Act
Indian Red Cross Society .Act.
The object of thesis cts are :
1) The benefit of the public by compulsorily requiring certain standards for
the status of qualified medical men, and
2)

Protection of medical men by conferring certain rights upon them.

The Central Acts of general application which are useful to medical doctors are

1) Indian Coroners Act
2)

Indian Contract Act

3)

Indian Penal Code

4)

Birth Death and Marriages Registration Act.

s 4 ;
purpose without the permission of government of India.
The fact that Red Cross
is allied with Medicine doctors and that medical practitioner is entitled to
use Red Cross emblem is fallacious.
The right to wear and exhibit the Red
Cross emblem is the right of only of members of the medical service of any
army.
It is not correct for medical doctors and nursing homes to use Red Cross
emblem.
It is completely prohibited by Government of India and the penality
may exceed Rs. 500/Indian Penal Code :
It is the Principal law dealing with punishment of crimes,
Doctors
are often called upon to give evidence as to the nature of an injury,
/■Again
doctors
themselves
oocldfs
rnemselves might be charged with having caused injury.
Therefore it
is necessary to note certain relevant provisions of the Indian Penal Code
relating to onysical injury.
Section 89,90,91,9/?93,3l2,313,314 and 315 and 320 of Inoian Penal
Code are of great help to the practitioners.
Sesides the law laid down by parliament known as the codified law
or statute law,there is judgement law or the body of the law created by
courts of law and it is called Law of Torts.
Tort is a french word for harm
or injury.
There are certain wrings caused by one man to another or another’s
property which are not covered by the law of Contract or Criminal law or
by any other law laid down by parliament.
The law does not allow such wrongs
to be without remedy.
On this principle the Court of England cencuries ago
evolved various principles
under which for wrongs which were neither
contractual nor criminal the caurtsgave Proper remedies.
This la w is known as
Common Law.
The law of Torts is part of Common law and Indian Courts even
after independance apply the same old English law of Torts.
Only some aspects
of tne law of Torts are of relevance to the medical profession.
Negligence is
the most important head of the laws of Torts which require attention of the
doctors.
If the doctor is negligent in the discharge of his duties he may
be sued for the damages by his patients.

Courts and their procedures
Courts are broadly classified as Civil and Criminal.
Procedure Code regulating the procedures of Civil Courts and a
Procedure Code regulating the Criminal courts.

There is Civil
Criminal

fhere are also certain other common rules such as the rules of evidence
contained in the Indian Evidence 4ct,
There is also an act known as Indian Limitation ^ct which lays down the
time limit within which the litigation may be commenced.
Criminal prosecution may be commenced any time after the commission
of offence.
As regards the Law of Limination touching civil actions two
provisions need to be mentioned, Viz. Article 36 and Article 115 of the Indian
Limitation Acts.
If a suit is to be filed on breach of contract either by the doctor
or by the patient it can be done within three years from the date of breach.

2 5 :
If the action is to be filed on the basis of Tortions,wrongs

t. e >, for breach of duty imposed by common law namely, law of Torts. The
action only be filed within two years from the date of the breach,
Act ions
filed beyond the period of limitation will not be entertained by courts of
law.
Civil Courts : There are three types of Courts defending upon the claims of
money.

a.) Courts of small causes — up to Rs* 30 0 0/b) City Civil & Sections CJurt

c)

up to Rs.

25000/-

High Court - above Rs- 25000/-

Consists of first and second class Magistrate Courts,
Criminal Courts
Sessions Court, High Court and Supreme Court.
Coroners Court is existing only in Sombay.
It is the court of enquiry
_
in cases over dead body lying within the jurisdiction as to how , when and
It is not the
where and by what means the deceased came by his or her death,
c )urt for trial and judgement.
Professional Negligence (Malpractices)
It is the absence of reasonable care and skill or wilful
.negligence of a medical practitioner in the treatment of a patient/as
lead to his/her physical/mental injury or death.

to

so

The action of malpractice may be brought against a practitioner in
a Civil or Criminal Court.
Hence the malpractice may be either Civil or
Criminal
Civil Malpractice : If the patient has suffered as the result of unskilled
treatment or negligence, the-burden of proof lies on the complainant for
the damages and compensation.
Prescribing over dose of medicine and
causing harm, giving poisonous drugs carelessly, leaving swobs during
operation, failure to prescribe A.T. serum, careless plastering in cases of
fractures, issuing false certificate of i’ll health, medical examination against
c insent, supply of drugs to the addicts etc.
Criminal Malpractice : Gross unskilled or unreasonable carelessness ih the
course of treatment resulting in serious injury or death of the patient by
acts of omission or commission or performance of certain acts in his professional
capacity forbidden by law criminal abortion.
Examples

Gross mismanagement of a case of -delivery, use of wrong drugs
in the eyes causing damage, imputation or operation on the wrong
limb.

Criminal malpractice is so serious that more money compensation is not
The punishment is severe and may be a teym of
adequate as in civil cases.
imprisonment.
Warning Notice and Disciplinary. Action 2

s 6 :
constitute on
infamous conduct but it stresses on the fact that it is not
the complete? list. The Council can also consider any form of alleged professional
misconduct which does not come with in any of the? categories contained in the
warning notice.
The name of the Practitioner will be erased from the register.
a) if he is convicted for any crime or offence of the nature of moral turpitude
and b)

if he performs any infa-’?ou?.

conduct in a professional respect.

The medical council does not take cognisence of any offence of misconduct unless
some one complains in writing.

HEP I CAL CERTIFICATES
They refer to illhealth, insanity, death etc.. They are accepted
in the Court of law only when they are issued by a qualified Registered
Medical Practitioner.
In case of illhealth the exact nature of illhealth should be stated
and the signature or the left thumb impression of the individual should be
taken at the bottom of the certificate.
A medical practitioner is legally bound to give a death certificate
stating the cause, of death without charging the fee, if the person dies whom
he has been attending during his last illness.
No death certificate should
be issued by the doctor unless he has inspected the body himself and satisfied
The certificate should not be delayed, even
that the person is really dead.
if the doctors fees for treatment is not paid.
More than ;ne death certificate
If needed a true cooy should be given.
should not be issued.
The certificate
shoulc not be given if the doctor is not sure of the cause of death or if
there is least suspicion of foul play and in such cases the matter should be
reoorted to the police.
Even in the case of death of a new born child a death
certificate is necessary.
From i960 the regulations of the W»H*0. are to be adopted in
mentioning the cause of death in the death certificate.
1)

Underlying causes disease or condition directly leading to death

2) Antecedent causes, if any, giving rise to the above cause
3) Other significant conditions contributing to death but not
the disease or condition causing it.

related to

MEDICAL PROTECTION
MEDICAL INDEMNITY

INSURANCE

*t is the broad based cover for professional liabilities.

It

was originally sponsored as a scheme by the Indian Medical Association for its
members and later extended to doctors who are not members.
It is in line with the organisations like Medical Defence Union
and Medical Protection Society in Western countries to promote and protect
the interests of the medical freternity.

t 7 :
Objectives of MedicAl

Ind^fnni ty Insura nee

1) To look after and protect
2)

Including prelitigation

Professional interest

of insured doctors

advise and all other
Professional
3) To in; —
assistance
; ^HPiiy the insured doctor in
respect
o(f
any
loss
directly arising ■ from
expense
DI.;’f*CtiOnS: Prnceedings, claims and
him on grounds of Professional negligence, misendutt i . demands against
°r or allegations of negligence arises the society
etc., ’hen disputes
any admission or i
contacted before
correspondence are entered into
L

U

Prnfessioh?^1^.--"011.13.^ mGa6t t°
Its purpose is to gaurti t het nf
a,f?ter the interests of the
paur-d the interests t ” ’ ’
medical person must bea law
court
from a
must always be attended. ' Faildro tong Citizen.
■-'i summon
summon from
\ikGly t0
to lead t0
to trouble,
attending the court when summoned is d0„!,t'1S likely
a
— National
duty”.

aSX‘2-4

s Jme one sues

must>in minor
yueven
your own interest,
matters nnri if 9

eStS

thS QDneral ^biic.

?ns r "

a position of a defendant
a11 your
7
oefence.
if y;
oefence.
you fail to do
If
SO even in minor matters and if
Counoh.
V™
th.
Y°u ca™ot nut
CouLi/rndiCal CaUnC11’
may be referred
up a defence about the
ujuncil Enquiry. 'f\ conviction in the
matter in the
open court is binding
Undersuch circumst
Council.
on the Medical
ances the council
death .sentence) without hearing
-------- - punishes you tWith professioial
you.
jjedical Evidence :
^ttonding cjurt on being summoned is a ”r- • ‘
doctor is called
duty”.
National
J he should discard all .ncumbcrances
such
When the
umbrella, news paper r
as
—
hat, over coat 9
or other impediments while <
looking something like
stepping into the witness box
3 a professional man and
original notes in the i
carrying
only his records and
case.
The

following simple rules willhelp the doctor in the witness box.

Be familiar i ’‘ ‘
uith details of your evidence before
Anticipate certain
entering the box.
..i likely questions and be
Prepared
to answer them.
2) Take all records,
r Ports of observation^
s made and other relevant
• Mever attempt to
Papers,
memorise*
The court allows
u you to refresh your memory.
3) Stand up. Do hot lounge with the hands
in ynur p Tickets )r lean
edge of the box.
over the
1)

4)

Sneak clearly.

5)

Use simple words.

ge honest.

Your only client is truth.
/Avoid medical jorgan.
6) Listen carefully to the
questions .
Give yourself time to think.
only what is asked.
7) Do not

evade

a question.

Say ”1 do not know” if it is so

Answer

t

? 8 :

8) Donrt lose your temper.

Don’t
Don’t argue.
argue.

Oust disagree if you do not agree.

9) Do not be drawn outside your field of competence.
10)

Do not discuss about the case with any one outside the court.

Books Recommended :
1) The Essentials of Forensic

Medicine - 8y Narayan Reddy
«■

2)

Medical Law and Ethics in India

3) (.-A Doctors Guide to Courtroom
4)

Hand Bo )k of Legal Medicine

By Mehta
- By Keith Sympson
- By -Allen Moritz

i

CM
DYING WITH DIGNITY
,

TVtwUT/t, /ctytaAAVi-fil Oa Hc xQ-vvojitvAcj:!
-i.
.
... curative
at. which
terrninaf m---Cancer reaches a stage
illness- like
treatment is no longer applicable,^palliat-ive-care is pus^lbj^. Doesfr^H2^^
W1----When a

mean that we are giving up the fight for recovery?

No. At means that fLf

nothing remains to prevent the illness from leading to death within a short,
forseeable period, attempts at curative procedures can be discontinued.
in undertaking heroic measures to proJong the dying
There is no point
process. So also, unnecessary investigations, including repeated blood
tests, should be avoided.
Quality of Life

The life expectancy of Cancer patients who are in the terminal phase,
having gone t from the curative to the palliative, phase, may be about three
months, on an average. When the length of life remaining is short,
to
improve the quality of life by relieving the patient of the symptoms <causing
distress. Help the patient to live with as little stress as possible.
Guard against over-zealous therapy.
Symptoms
Terminally ill people can have a variety of disturbing symptoms.
These may be physical, psychological, family-related^social and spiritual.
Among the symptoms are
Chronic pain - continuous and Gften intolerable.
Dyspnoea, with considerable amount of secretionswhich
cannoj, be brought cut easily.
Digestive disorders, including diarrhoea and constipation;
lack Qf appetite; difficulty in swallowing.
bounds and bed sores from prolonged bedridden state
Difficulty in urination and incontinence.
d

Ankylosis of joints and restriction of movements,
Delirious episodes; loss of memory.
Anxiety.

PaiKative care
The disturbing symptoms must be relieved.
care.

The answer is pa®iative
It improves the quality of life and comfort before death, It :ls a

neglected area.

Patients suffer needlessly.

In the case of the terminally ill, paMtatitz^care may have to be
continued for quite long periods. Paifaative care needs training of the
caring people, to give physical, psychological, social and other support.

: 2 :
Should hospitals set up paiZiative care units, just like intensive
care units? Should there be special wards for the terminally ill in
general hospitals?

*

The needs of the terminally ill are different^"they

often withdraw from all activities.

They need the presence of close

relations. Their religious and spiritual needs must be met. All these
need changes in the hospital regulations and attitude of the personnel/.
The jStaff looking after the terminally ill

in the hospital needl

apart from special training, support. They may suffer from psychological
problems, being constantly in the midst of death and dying. Many hea th
care persons have doubts about the methods used for mitigating pain and
the result.
Management of Pain
C
Skilful management of pain should diminish pain»thronic pain can
reduce efficacy of treatment and also reduce the immune response of the
body. There is often a fear whether the action that is being taken will
hasten death.
important.

Lu

Will it be euthanasia?

If the intention is to

The intention behind the action is

relieve pain and not to hasten death,

which may happen indirectly, then it is not wrong. But, if the intention
is to hasten death, thereby relieving pain, it is • wrong.
Hospital or Home?
Does the terminally ill patient wish to die at home or in the hospital?
A/Survey 4 among healthy individuals in Italy(l99l) showed that 64% wished
to die at home, if they became terminally ill. So also, a survey among the
terminally ill showed a similar preference.
ate that

The advantages in being at home

. The entire family can show love, compassion and caring, and
. the patient is in familiar surroundings.
Patients wishes must be respected. If the patient wants to return
housx^ he/she must be allowed to do so. In such cases, there is need to
. inform the people at home of the exact condition and what
can be done^
. have local volunteers who can help and work with the doctors
and nurses attending on the patient,
. develop the knowledge, skills and attitude of the people caring
end for the patient^
• make available necessary resources.
.3.

: 3 :
Hospice
The hospice movement for the care of the terminally ill is gaining
momentum.

The programme aims at placing the terminally ill in comfortable

situations, where the patients and their families are given support.
Medical, nursing, social, religious and other persons are involved in the
care. They help the patient and the family to cope with the stress of
dying and to make difficult decisions.
Culture.
It is necessary to work out the best ways of looking after people
in accordance with the culture and traditions of the people.
In some Asian and African countries, death is dealt with in a broac. social
basis.

The family of the dying and

bereaved get collective support from

the community. Relatives, friends and neighbhours of the terminally ill or
and prayers
deceased come together and render support. Communal
mark the cultural framework for dying.
Dying has another dimension in cultures wh^re the people believe* in
re-incarnation or rebirth, $n Thai culture(Budd^jst), more is required
than competent medical care, humane maintenance and loving care. Buddhism
sees .life and death as one phase of an endless process. The ultimate aim
is total deliverance from the cycle of life and death. To enable the cyin-g
to attain this goal(Moksha), spiritual care is to be given.
accomplished if the terminally ill retains consciousness.
pain relief is to be maintained such

This can be
The level of

that the insight and awareness of the

impermanent, unsatisfactory and non-substantial nature of life

are present.

Paffetivze^Care in other conditions
The principles of paitiativtcare are essentially those of humane
health care.

Cancer patients were singled out because it has been the more

common condition where there is prolonged physical and psycho-social distress
before death.

Palliative care should be available in other similar

conditions, such as the terminal stages of AIDS.

There is need to prevent

unnecessary suffering and to improve the quality of the remaining life.

DYING IVITH DIGNITY

When a terminal illness like Cancer reaches a stage at which curative
treatment is no longer applicable, palliative care is possible* Does it
mean that we are giving up the fight for recovery? No. it means that if
nothing remains to prevent the illness from leading to death within a abort,
forseeable period, attempts at curative procedures can be discontinued4
There is no point s in undertaking heroic measures to prolong the dying
process. So also, unnecessary investigations, including repeated blootfl
tests, should be avoided*
Quality of Life
The life expectancy of Cancer patients who are in the terminal ph]i^se,
having gone p from the curative to the palliative phase, may be about three
months, on an average, When the length of life remaining is short, try to
improve the quality of life by relieving the patient of the symptoms causing
distress. Help the patient to live with as little stress as possible.
Guard against aver-zealous therapy.
Symptoms
Texminally ill people can have a variety of disturbing symptoms.
These may be physicalt psychological, family-related social and spiritual*
Among the symptoms are
Chronic pain - continuous and aften intolerable*
Dyspnoea, with considerable amount of secretion which
cannot be brought out easily.
Digestive disorders, including diarrhoea and constipation!
lack of appetite! difficulty in swallowing.
bounds and bed sores from prolonged bedridden state
Difficulty in urination and incontinence.
Ankylosis of Joints and restriction of movements,
Delirious episodes! loss of memory.
Anxiety*
Psthative care
The disturbing symptoms must be relieved, The answer is pathative
care. It improves the quality of life and comfort before death. It is a
neglected area. Patients suffer needlessly.
In the case of the terminally ill, pathatic care may have to be
continued for quite long periods. Pathative care needs training of the
caring people, to give physical, psychological, social and ottyir support.

t 2 t

Should hospitals set up pathiative care units, just like intensive
care units? Should there be special wards for the terminally ill in
general hospitals? The needs of the terminally ill are different, they
often withdraw from all activities. They need the presence of close
relations. Their religious and spiritual needs must be met. All these
need changes in the hospital regulations and attitude of the personnels.
The Staff looking after the teiminally ill win the hospital need,
apart from special training, support. They may suffer from psychological
problems, being constantly in the midst of death and dying. Many health
care persons have doubts about the methods used for mitigating pain and
the result.
Management of Pain
Skilful management of pain should diminish pain chronic pain can
reduce efficacy of treatment and also reduce the immune response of thp
body, There is often a fear whether the action that is being taken wiil
hasten death. Will it be enthanasia? The intention behind the actioi is
important. If the intention is to relieve pain and not to hasten des 9
which may happen indirectly, then it is not wrong, But, if the intention
is to hasten death, thereby relieving pain, it is s wrong.
Hospital or Home?

J

Does the teiminally ill patient wish to die at home or in the hospital?
A Survey
among healthy individuals in Italy(l99l) showed that 64% fished
to die at home, if they became teiminally ill. So also, a survey amohg the
terminally ill showed a similar preference. The advantages in being at heme
ate that
• The entire family can show love, compassion and caring, and
• the patient is in familiar surroundings.
Patients wishes must be respected. If the patient wants to ret urn
house, he/she must be allowed to do so. In such cases, there is need. to
• inform the people at home of the exact condition and what
can be done.
• have local volunteers who can help and work with the doctors
and nurses attending on the patient,
• develop the knowledge, skills and attitude of the people eating
and for the patient.
• make available necessary resources.
...3.

t 3 i

Hospice
The hospice movement for the care of the terminally ill is gaining
monentum* The programme aims at placing the terminally ill in comfortable
situations, where the patients and their families are given support*
Medical, nursing, social, religious and other persons are involved i^ the
care. They help the patient and the family to cope with the stress of
dying and to make difficult decisions*

Culture
It is necessary to work out the best ways of looking after peopl e
in accordance with the culture and traditions of the people*
In some Asian and African countries, death is dealt with in a broad sodial
basis. The family of the dying and bereared get collective support fran
the community* Relatives, friends and neighbhours of
terminally ill or
deceased come together and render support* Communal signing and prbyers
\ (
mark the cultural framework for dying*
'

■

Dying has another dimension in cultures where the people believb- in
re-incarnation or rebirth, in Thai culture(Buddist), more is require^
than competent medical care, hwnane maintenance and loving parowsBuddhism
atISMxfe and death as one phase of an endless process* The ultimate aim
is total deliverance from the cycle of life and death* To enable the dyin-g
to attain this goal(Moksha), spiritual care is to be given. This c^n be
accomplished if the texminally ill retains consciousness. The level of
pain relief is to be maintained such a that the insight and awareness of the
impermanent, unsatisfactory and non-substantial nature of life* are present*
Pfrthatic Care in other conditions
. . ..

.....

. .

The principles of pathiatic care are essentially those ol? humane
\

health care* Cancer patients were singled out because it has been the more
common condition where there is prolonged physical and psycho-social distress
before death* Palliative care should be available in other similar
conditions, such as the terminal stages of AIDS*

There is need to prevent

unnecessary suffering and to improve the quality of the remaining l^Lfe*

, \f<d Vol. 35. No. 4. pp. 425 -432, 1992
m Great Britain. All rights reserved

0277-9536/92 $5.00 -F 0.00
Copyright © 1992 Pergamon Press Ltd

in "
Pedro La Ug.Jna
poliiicai constraints m
<udx from Indonesia
by Merle} D. Rohdc
—8. Oxford Vniversiiy
•mmunitx participation
of the problems and
fA’A 1.121.57-63. 1987
-.:iy participation: case
Heahh For All (Edited

.jams G.|. pp. 190-207
i 1983.
pular participation in
Plan. 2. (2). 162 170.
W. M.. Hoffman M.
•■pation in the Mamrc
'. .Med. J. 74,335-338
mmunity organization
ent of current progress
. 55-65. 1985.
ealth workers. Report
. Douala. Cameroon.
^FR
226. Brazn. Qu. -.in: WaltG.
tn crisis? Hlih Policy
.rammes in crisis? Hlih
health care: victims in
?n. Soc. Sei. .Med. 20,
Local politicization of
:ent for development:
workers in Zambia.
<0. 1985.
-.ougen K. Are largeworker programmes
soc. Sci. .Med. 29, (5)
communitv partici?2. 1986.
Provincial Medical
—ization in primary
Sci. .Med. 19, (3).

SECTION F
DYING WITH DIGNITY
T. N. Madan
Institute of Economic Growth, Delhi-110007, India
Abstract—Death is a theme of central importance in all cultures, but the manner in which it is interpreted
varies from society to society. Even so, traditional cultures, including Christian, Hindu and Jain religious
traditions, exhibited a positive attitude to death and did not look upon it in a dualistic framework of good
vs bad. or desirable vs undesirable. Nor was pessimism the dominant mood in their thinking about death
itself.
A fundamental paradigm shift occurred in the West in the eighteenth century when death was
dcsacralized and transformed into a secular event amenable to human manipulation. From those early
beginnings, dying and death have been thoroughly medicalized and brought under the purview of high
technology in the twentieth century. Once death is seen as a problem for professional management, the
hospital displaces the home, and specialists with different kinds and degrees of expertise take over from
the family. Everyday speech and the religious idiom yield place to medical jargon. The subject (an ageing,
sick or dying person) becomes the object of this make-believe yet real world. As the object of others’
professional control, he or she loses the freedom of self-assessment, expression and choice. Or, he or she
may be expected to choose when no longer able to do so. Thus, not only freedom but dignity also is lost,
and lawyers join doctors in crisis manipulation and perpetuation.
Although the modern medical culture has originated in the West, it has gradually spread to all parts
of the world, subjugating other kinds of medical knowledge and other attitudes to dying and death. This
is regrettable because traditional cultures may provide alternative perspectives, which, if taken seriously,
may help correct some of the excesses of modern attitudes, introduce a measure of humaneness to the
practice of medicine and surgery, and restore some freedom and dignity to the old, the sick and the dying.
The argument is not in support of religious revivalism, but in favour of the values of cultural and
individual autonomy and familial responsibility, combined in one holistic paradigm in which death,
considered a normal aspect of living, is encompassed by life, and thus not its simple opposite. Prolongation
of life, even when technically feasible, may fail to provide an acceptable level of quality of life and,
therefore, of dignity.
Key words—medicalization, meaninglessness, self-control, good death, dignity

1. INTRODUCTION

In what turned out to be the last of his numerous
talks to western audiences, delivered at Sanen in
Switzerland in the summer of 1985, some months
before his death early in the following year, the wellknown Indian mystic, Jiddu Krishnamurti, said:
IX-ath. talking about it, is not morbid. It is part of our life.
I ioni childhood maybe till we actually die, there is
•ilways this dreadful fear of dying . . . We have put it as far
away as possible. So let us enquire together what is that
extraordinary thing that we call death [1, p. 103].
1 have chosen to begin this article with the fore
going quotation because it juxtaposes in clear and
simple language the modern and traditional attitudes
io dying, represented respectively by silence and
speech. The former is rooted in deep hopeless fear
and the latter in equally deep, if not deeper, con
fidence. The hopelessness flows from seeing death
as the end of a good thing, namely life, while the
hopefulness or confidence arises from the faith or
Gmviction that life encompasses death and is not
425

.

■

.

overwhelmed by it. The speechlessness of incompre
hension is confronted with the articulation of the
affirmation of death as an aspect of life. Hence
Krishnamurti’s invitation to his audience to talk
about it.
Folklore, ethnography, literature, religious philos
ophy, psychoanalysis, systems of medicine, etc. all
bear witness to the universal concern about death as
a threat to life. All cultures see the threat emanate
sometimes from outside the individual and sometimes
from within him or her. (Henceforth, for the sake
of convenience, male pronouns will be used to
refer to both genders.) Malevolent spirits, vengeful
human beings, poisoned foods, polluted environ
ment, and other such phenomena may be seen to
invade and break through the spiritual and physical
protective boundaries of the individual. Or, he may
be threatened by some internal flaw, whether ‘ignor
ance’, ‘karma’, or ‘the death wish’. What is a threat
to life is not yet its cessation. It is only when these
external and internal threats are regarded as more
real than life, at least more powerful, that the loss

T. N. Madan

426

??

of confidence and despair, and indeed the loss of
dignity, set in.
2. WESTERN PERSPECTIVES

In his erudite inquiry into changing western
attitudes to death, over a thousand years, Philippe
Aries [2] maintains that the early Christians inherited
from the Greco-Roman world an attitude towards
death which was not marked by fear. Death was a
collective destiny and therefore not fearful. More
over, there were other comforting ideas, notably
those of the ‘second coming’ of the Saviour and the
promise of a blissful afterlife. Aries calls this the
‘tame death’.
According to him, a major shift in consciousness
occurred, mainly during the eleventh century, co
inciding with the emergence of the individual and
the retreat of the group or community. An intense
concern with one’s sense of the self, and also with
the death of the self, were the key characteristics of
the new attitude. This ‘turning of the tide’ led in
modern times (the nineteenth century) to the notion
of death as separation, as a catastrophe, and as
sorrow. Finally, in the present century, a further
radical alteration in the western man’s consciousness
of death occurred through the ‘medicalization’ of
death as a result of which it came to be denied. Death
became a shameful thing, an embarrassment, even
dirty and indecent. “Death has ceased to be accepted
as a natural, necessary phenomenon. Death is a
failure, a ‘business lost’” [2, p. 586]. In short, death
loses contact with human dignity.
Aries concludes his study pointing out that by
transforming the phenomenon of death from a re
ligious and social to a technical and individual prob
lem, modernity offers two choices. “The first is a
massive admission of defeat. We ignore the existence
of a scandal that we have been unable to prevent;
we act as if it did not exist, and thus mercilessly force
the bereaved to say nothing. A heavy silence has
fallen over the subject of death. When this silence is
broken ... it is to reduce death to the insignificance
of an ordinary event that is mentioned with feigned
indifference ” [2, pp. 613-614], Either way dying is
robbed of dignity: neither the individual nor the
community has the moral strength to recognize
the ever-present possibility of death as a normal
phenomenon.
The seeds of the attitude which sees death as defeat
lie in the secularized world view of the Age of Reason.
By inviting man to dare to know and to take charge
of his fate, that is to make his own history, the
Enlightenment rendered the idea of the limitation of
human capabilities unintelligible, if not illegitimate.
The birth of the clinic and the ‘power’ of the phys
ician over other human beings, through a supposed
ability to prolong life (Francis Bacon, among others,
propagated this idea), and over human life follow
from this development [3].

The ‘disenchantment of the world’ and the pro
cesses of rationalization of which Max Weber wrote
also meant the displacement of ultimate values
by instrumental values. The latter when elevated
to the level of the former contradict themselves
and life becomes meaningless, and so indeed does
death. Weber maintained that nobody in the modern
west had confronted this question more directly
than Leo Tolstoy, according to vVhom death had
no meaning for civilized man. W6ber commented:
“it has no meaning because the individual life
of civilized man, placed into an infinite ‘progress’,
according to its own immanent meaning should never
come to an end; for there is always a further step
ahead of one who stands in the march of progress . . .
And because death is meaningless, civilized life as
such is meaningless; by its very ‘progressiveness’
civilized life gives death the imprint of meaningless
ness” [4, p. 139-140].
Other scholars also have linked the meaningless
ness and lack of dignity in the modern concepts of
death and dying to the invasion pf human life by
technology. Thus, Ivan Illich points out that, in
western society, the medicalization of death redefines
death, which as a ‘natural’ phenomenon might have
some meaning and even dignity attached to it, and
reduces it to something very mechanical, “the ulti
mate form of consumer resistance”: “natural death is
now that point at which the human organism refuses
any further input of treatment” [5, p. 149]. This might
well be seen as the ultimate indignity in which the
modern world envelopes dying. And, as Illich points
out, “The white man’s image of death has spread with
medical civilization and has been a major force in
cultural colonization” [5, p. 123].
Modern notions of institutionalized care of the
ageing and the dying, the phenomena of the old-age
home and the hospital, on which modern society
prides itself, initiate a process of isolation of those
who are still alive and even healthy at their age
[6, 7], or dying but not unaware of their condition
and of the reaction of normal people around
them. As N. Elias puts it, “if a person must feel while
dying that, though alive, he or she has scarcely any
significance for other people, that person is truly
alone” [6, p. 64],
The loneliness of the ageing or dying person is
multi-dimensional and includes removal from amidst
one’s family members and friends to be placed among
strangers or specialists. One loses significance as an
active decision-making member of society and is
reduced to being a dependent of those whose pro
fessional duty (which is very different from kinship
obligation or friendly concern) it is to take care of
such ‘cases’. If ageing or dying is accompanied by
excitement, depression or pain, as jt often is, one is
put on tranquilisers, anti-depressams, or pain-killers,
which are undoubtedly welcome to the subject in his
helplessness as they relieve him of immediate distress,
but they also gradually erode his self-esteem. One is

Dying with dignity
Id’ and the pro.
lax Weber wrote
ultimate values
r when elevated
adict themselves
so indeed does
Jy in the modern
n more directly
horn death had
her commented:
individual life
finite ‘progress’,
ing should never
s a further step
h of progress...
civilized life as
progressiveness ’
of meaninglesshe meaninglessern concepts of
human life by
ts out that, in
dea
defines
rion might have
.ched to it, and
nical, “the ultinatural death is
rganism refuses
'.49]. This might
:> in which the
as Illich points
has spread with
~ajor force in
:=c care of the
of the old-age
“odem society
li’jon of those
;• at their age
±>eir condition
reople around
feel while
a- sea’■rely any
rers:
truly
iz person is
amidst
among
±eir.ee as an
.
and is
-r.'.se prokinship
• z eare of
— Tamed by
one is
• r.-killers.
. .7 -x: in his
z - .z distress,
One is

, more oneself. As Illich puts it, perhaps with brutal
r ankness. “increasingly pain-killing turns people into
Jnfccling spectators of their own decaying selves”
is p. 108].
The dying sometimes graduate into the special
c itegory of terminally ill patients. In technologically
M*dvinccd countries they are handed over to machines
■ nd monitors to which they are chained by the wires
nd tubes of dependency. The patient is now dehunrmized and the decision when to stop is that of the
specialists, sometimes doctors and sometimes
lawyers. There is an emphasis on so-called scientific
objectivity and emotions—the doctor’s, the patient’s
and the relatives’—are banished. The irony of it all is
that the patient, being a terminal case, is offered no
assurance of anything beyond that the offerings of
modern medicine will be pressed into service to
prolong life and, perhaps, deaden the capacity for
feeling.
David Moller, a sociologist, in his study of dying
cancer patients in America [8], calls this a ‘double
failure’: the dying patient is denied humane care and
understanding and is at the same time stigmatized,
without being offered any hope of recovery. The only
question that then remains, as one of the doctors
quoted in Moller’s book asked his superior, is, “what
do we do with the body?” Such a patient crosses
before his death the threshold beyond which dignity
or its lack, the comfort of company or loneliness, lose
all meaning. And yet modern medicine deems it a
challenge to keep him alive, and the same is clothed
in high-sounding, but empty, rhetoric about medical
ethics. Any consideration of the quality of life is
pushed aside.
It is not at all surprising that the modern medical
culture has come to generate extremely critical reac
tions on both philosophical and practical grounds.
There is not only passionate criticism [5, 9], but also
heightened interest in euthanasia [10]. Widely publi
cized cases of people like Nancy Cruzan (d. 1990) and
Janet Adkins (d. 1990) further highlight the fact that
extremist situations generate extremist solutions.
To recall briefly, Nancy Cruzan suffered brain
damage (due to oxygen deprivation for a quarter of
an hour) following a car accident in 1983 when she
was 24 years old. Her parents and husband sought the
best medical help, but it was clear within a few
months that it would be impossible to bring her out
of her vegetative state. They then sought disconnec
tion of the support systems to let her die. The hospital
refused to do this without legal authorization, but
this was not forthcoming because the law in the
state of Missouri required the patient’s consent.
It took seven years to overcome this hurdle
and Nancy was allowed to die only towards the
end of December 1991. Meanwhile her husband
bad ceased to be her husband, but her parents
had fought with great perseverance to restore some
dignity to their daughter’s ‘life’ and end their own
deep suffering.

427

While Nancy Cruzan was still in an unconscious
state, Janet Adkins, a 53-year old, physically fit,
woman, recently diagnosed to be suffering from some
early symptoms (forgetfulness, etc.) of Alzheimer’s
disease, and unwilling to see herself gradually losing
self-control and dignity, ended her life. She was
able to do this painlessly by injecting a lethal
substance into her body with the help of Dr Jack
Kevorkian and his ‘suicide machine’, the use of
which he had explained over television earlier in
the year. The Michigan court, which was asked to
determine if Dr Kevorkian was guilty of abetment
in murder, ruled that Janet Adkin’s decision was
freeely and entirely her own. Doubts, however,
remain whether her decision was not a ha$ty,
premature action arising out of depression and
whether the doctor had not violated professional
ethics. He has since published a book defending his
position.
The involvement of the legal process in both these
cases brought up a fundamental issue which the
courts were asked to decide: namely, who is the
ultimate repository of the right to decide if and when
to end a human life—the state, the doctor, the
individual’s next of kin, or the individual himself?
The rights of the state in this regard are not well
defined in respect of situations of the kind that were
under consideration, for Nancy Cruzan was guilty
neither of murder nor of high treason. Moreover, did
the state have a constitutional right to keep people
alive? Given the central importance individualism has
acquired, over the last several hundred years, as a
dominant ideology in western culture (deriving
strength from classical Greek thought and from the
later teachings of the Christian Church), it was only
to be expected that the right to die would be regarded
as one among the fundamental rights of the individ
ual. The state through its judicial arm would be the
guarantor of this right.
Naturally, the U.S. Supreme Court decided
(though only by a majority of 1, 5 against 4), on 25
June 1990, that Nancy Cruzan’s parents could not
exercise on her behalf the constitutional right of
competent people to refuse medical aid [11]. And the
unconscious Cruzan was not competent. It is obvious
that under exaggerated emphasis a value becomes a
dis-value: the subject of this case was a victim of one
of her own inviolable rights as an individual. The
failure to raise and answer the question whether such
assertion of an individual’s rights truly enhances his
dignity, or prevents unnecessary human suffering,
was the proverbial default. Public pressure finally
persuaded a lower court to accept the testimony of
Nancy Cruzan’s friends that, before her accident,:she
had said that she would not want to live in the
vegetative state which was later to become her own
condition, and she was allowed to die.
Dramatizing the conflict of strongly-held opinions,
we have the runaway success of Derek Humphrey’s
book. The Final Exit [12], Here a whole range of

I
r

428

T. N. Madan

options are explained in the typical American ‘do-it- the problem of death, but, owing to limitations of
yourself' style for the benefit of those who want to space, I can present only two statements here, one
end their life. The numerous buyers who purchased very briefly and derived from the Sanskritic literary
the book must have included thousands who were tradition, and the other in some dptail and based on
simply curious (that is non-serious) rather than con
ethnography.
templating suicide. The phenomenon thus under
scores the fact that dying is trivialized as much by Hindu textual tradition
making it easy' as it is robbed of dignity by its being
It used to be customary among high caste Hindu
made difficult.
families—and the practice is continued until today in
We are here faced with a total collapse of values.
many tradition-oriented homes—to read aloud cer
To quote Max Weber again: “Whether life is worth tain parts of the religio-philosophical text, called
living and when—this question is not asked by medi
the Bhagavad Gita, in the presence of a dying person.
cine. Natural science gives us an answer to the The passages usually chosen introduce an inner-self
question of what we must do if we wish to master and outer-self, or subtle-body and physical-body,
life technically. It leaves quite aside, or assumes
dichotomy. This dichotomy is not employed to dis
for its purposes, whether we should and do wish to
miss the physical body as dross or evil, but to
master life technically and whether it ultimately characterize it as perishable, and therefore imperma
makes sense to do so” [4, p. 144]. Weber’s inspiration
nent, by its very nature. One’s sense of personal
was Tolstoy’s message, conveyed through his identity is sought to be constructed from the totality
later novels and stories, including The Death of Ivan
so that death is not seen as threatening to one’s sense
Illich, that only those who know how to answer the
of selfhood’, and the idea of prolonging the life of the
question How shall we live?” can cope with dying physical body is seen as unnecessary, although its
gracefully.
maintenance in a state of health (for example through
Dignity does not come to the dying from immoryoga) is emphasized. Actually, ancient Hindu medi
tality fantasies, or compensatory ideas, such as cine is called ayurveda, the science of longevity;
reincarnation and paradise, nor does it come from
moreover by including it in the vedic corpus it is given
empowerment through modern medicine. It comes the status of the highest knowledge.
from the affirmation of values, not only up to the
The problem of the finiteness of the physical body
boundary of death as some scholars seem to suggest
is tackled by refusing to give it the status of a problem
[13], but in a manner that encompasses dying under and by accepting death
i as a normal happening. What
living and does not oppose the two in a stern dualistic is expected to happen should not be a cause for
logic. To illustrate what I mean by this, I will turn
sorrow and grief. The Bhagavad Gita says that the
briefly to thinking about death in Hindu and Jain
worn-out body is like an old set of ilothes, and that
cultural traditions. Needless to say, this thinking has
“all things born in truth must die; and out of death
been evolved in pre-technological environments, but
in truth comes life” [14, p. 50]. If dying is such an
survives, even if weakly, in modern times.
ordinary, routine, though in a sense important, oc
3. INDIAN PERSPECTIVES

The quotation from Jiddu Krishnamurti with
which this article opens refers to death as an extra
ordinary thing. The extraordinariness of death implies
a positive value. In the Hindu tradition Death is
defined as the personification of time (Mahakala) as
also of the very foundation of the cosmo-moral order
(Dharma). Without death, in other words, there
will be neither meaningful life nor ordered society.
This is, of course, a metaphysical idea, and that
should be permissible, for I have tried to show in the
second section of this paper that a technological or
legalistic view of death leads to its trivialization.
There are many ways in which Hinduism copes with
*Thus, J. L. Mehta, a philosopher who was equally at home
in Western and Indian philosophies, told a Harvard
audience of theologians and students of comparative
religion in June 1988, just a month before his own death:
Not until living itself is transformed into a pilgrimage,
which is nothing if not living in the face of death, one's

own, does Scripture disclose its sovereign majesty
become truly Scripture" [16, p. 12].

currence, how then does one refer to it as ‘extraordi
nary’? And Krishnamurti was ofily echoing the
Hindu metaphysical texts called the upanishads when
he used the term.
The Hindu answer to this question would seem to
be that it is in the presence of death that life’s deepest
significance becomes manifest and the moment of
death certifies the encompassing character of life or,
in other words, the supremacy of life over death. In
the Katha Upanishad the questioner learns from the
god Death the secret of life in answer] to his question
about the significance of “the greit passing on”
[15, p. 607], namely that the knowing self is never
born, nor does it ever die [15, p. 616], If texts that
are more than a thousand years old seem remote, let
me add that many contemporary Hindu religious
philosophers base their thinking oh ideas derived
from them.*
And not only philosophers, but common people
too. who are the subjects of ethnography, do so. But
before I present the evidence of ethnography, I would
like to emphasize that the upanishadic idea of the
illumination of life by death is the vdry opposite of
the notion of modern medicine, couched in Bichat's

Dying with dignity

? 10 lln’‘lations
tements here.
Sanskritic |ilcr
“tail and based on

-Open a few corpses: you will dissipate
1 |.irkness that observation alone could not
and paraphrased by Foucault thus: “The
^'^• night is dissipated in the brightness of death”
| V p ^b]

hiSh caste Hindu
ned until today in
read aloud ccr.
hical text, called
a dying person,
luce an inner-self
d Physical-body,
employed to dis*
or evil, but to
erefore impcrnia-nse of personal
from the totality
ng to one’s sense
ing the life of the
ry, although its
exarr
’.hrough
.nt h,..au medi-e of longevity;
corpus it is given
ie physical body
lus of a problem
appening. What
be a cause for
a says that the
lothes, and that
nd out of death
• ing is such an
important, ocil as ‘extraordiy echoing the
wiishads when
would seem to
it life's deepest
ne moment of
-ctei
ife or.
over ueath. In
:arns from the
.0 his question
passing on”
i self is never
If texts that
em remote, let
ndu religious
ideas derived
mmon people
-.y. do so. Bui
aphy. I would
c idea of the

. opposite of
_c in Bichat’s

^idence
hllve conducted fieldwork among Hindu villagers
(he*Kashmir Valley in north India. These Hindus,
,n
m ethnographic literature as Kashmiri
in
V'1'Ls belong to the Brahman caste and have a
Pandits, belong to
Undeveloped lore about death and dying [17]. They
maintain that the most irrefutable evidence of how
^ihk ! a life, in moral rather than material terms, has
been becomes truly known only at the time of death:
t(,d death certifies a good life. In the Pandits’
a V>*
judgmci•nt death is not the ending of an individual life,
but its completion for the time being, for they
entertain the idea of reincarnation. The hour of
death finally portrays the goodness or otherwise of a
person’s life and also uniquely anticipates the future.
In other words, the manner of one’s passing out
weighs all previous claims and intimations of one’s
moral worth. Death is, therefore, indeed an extra
ordinary event.
The Pandits have evolved an elaborate typology of
deaths. Thus, they speak of the good death, “the
great passing on” (parmagati) which does not just
happen, but is achieved or attained. If one is able to
lei go or renounce the ‘life-breath’, in full conscious
ness. at a time and place of one’s choosing, one dies
m a state of dignity. This folk idea, of course, echoes
the upanishadic last wish of the dying person that, at
the moment his body turns to ashes (the reference is
to the Hindu practice of cremation) and his life
breath merges with the undying wind, he should be
in full command of his faculties and remember all
past deeds [15, p. 577].
The main elements of the notion of the good death
arc the place (desh\ the time (kala) and the moral
physical slate of the person (patra) at the time of his
death. The best place to die, according to the Pandits,
is in one’s home, the house in which one has lived,
for many men this would be the house where one was
born, but in the case of women it would be the house
where one has lived after marriage and where one has
borne and raised children. The house is not regarded
merely as a dwelling, but as the microcosm of the
universe, it stands on sanctified ground and has a
presiding deity. Inside it the Pandit householder
pursues his legitimate worldly goals of self-fulfilment
and seeks to improve the moral quality of his self or
person. It is, therefore, right and proper that he
’‘hould die here.
I he only preferred alternative is to die in a holy
place of pilgrimage (such as Hardwar or Kashi in
north India), but this is perhaps considered more
appropriate for unattached persons who do not have
any immediate kin, or who are believed to have over‘•ome worldly attachments in the manner of, for

429

example, renunciants. Jonathan Parry, a British
anthropologist, has written that the significance of
dying in Kashi [18] lies in not only the high sanctitity
of the place but also in the deliberate choice that| is
made to die there. It should be added that there are
interesting variations on this theme, and traditionminded men of the second highest caste, the
Kshatriyas or Rajputs, consider dying on the battle
field as the most glorious death, “the brave man’s
way of passing on” (viragati). The emphasis, it
should be clear, in both cases is on choosing: one
must be in command and should not be overtaken by
death. To be so overtaken is the loss of dignity.
To die at home is not enough to constitute a good
death. The second crucial element is the hour of
death, that is one must die at an astrologicajlly
appropriate time so that a smooth passage from the
world of human activity to the worlds beyond is
assured. Again, the Pandits emphasize that those who
have attained moral excellence through knowledge,
good deeds, yoga, etc., can indeed choose the moment
of death just as they can choose the place of death.
Stories of particular deaths are told to illustrate and
validate this contention. Needless to say, a great deal
of myth-making and fabrication goes into the making
of these tales of edification. Their significance does
not lie in their veracity but in the values and ideals
they uphold.
Then there is the third and last element of the
good death, viz. the personal condition of the subject.
Has he lived a long life marked by the fulfilment of
the legitimate wordly goals of righteous actions,
religious devotions, wealth, progeny (particularly
sons), and ‘good name’ (even fame) in society?
Has he discharged all family and social obligations
and not been predeceased by those younger than
himself? In the case of women, the husband
though older should be one of the survivors. Finally,
were the last moments of death conscious, easy and
peaceful, without being preceded by a long, painful
illness? If the answer to all these questions is in |he
affirmative, then one has indeed died in not only
peace but also dignity. Such a death is dignified and
extraordinary because it symbolizes so many positive
values of Pandit culture—in fact of Hindu culture
generally.
A community which entertains a notion of the
good death may be expected to complement it with
a notion of the bad, undignified, death. It is marked,
the Pandits maintain, by the loss of control over one’s
worldly position, family affairs, and, above all, over
one’s body and mind. Further, these Hindus allso
entertain the notion of what may be called ‘anomic’
death, that is death which raises misgivings, even if
only temporarily, regarding the fragility of the moral
foundations of human life. The death of an pld
couple’s youthful son, married and having young
dependent children, is the prime example of what the
Pandits call 'untimely' death, but this literal trans
lation of the Sanskrit words akala mrityu harply

T. N. Madan

I

i

1

ii

of personal sorrow and moral ahimsa. Like the Pandits. Jains of the Digambara
are sought to be conveyed when they sect, too, have an elaborate typology of deaths
aiso refer to such a death as anartha, consisting of 48 named types broadly grouped into,
<'/■- and meaningless,* and even as pralaya, first, ‘childish or foolish death’, second, ‘wise death’,
'.■•//iution of the cosmo-moral order, for it and third, ‘the wisest of the wise deaths’ (panditapandita-marana) [20,21]. Suicide falls in the first
>e natural moral ordering of events.
foregoing brief characterization of the good category and the fact that it may be a consciously
relation to the bad brings out clearly that chosen death is of little avail. It is marred by
,rocc morality what cannot be cured has to be attachment (the desire to die) as well as violence.
There is ample evidence, however, that the
Jf the end of one’s life is to be enveloped
Jains have practised self-initiated ritual death for a
in oe indignity of total loss of control, one can
: ■■jbrrnt to this fate, one’s karma, in the hope very long time and considered it to belong to the
’h< whatever follows death may be better. Max category of ‘the wisest of the wise deaths . There
has pointed out that, looked at from the are many recognized ways of achieving it, such as
v-';.'err. perspective, the “karma doctrine trans- renunciation, worship, prayer, meditation, knowl
forr.v/; the world into a strictly rational ethically- edge, and above all, fasting (sallekhana}. Before a
dev-'mmed cosmos: it represents the most consistent monk or nun embarks upon such austerities, he
’b'/z^cy ever produced in history” [19, p. 121]. That or she has to be fully convinced that the outer-body
suer, a world view, perhaps, had its cost—‘other- (kaya) is the enemy of the inner-self (alma) and,
v'or/;Jjbcss ’ in Weber’s judgment—is an issue that therefore, slow withering of the body is the best
way to burn out the burden of karma that remains
d</:s not concern us here.
1 ne Hindu attitude is shared in some measure by at the end of a lifetime of virtue, cleanse the inner
•he other indigenous religio-cultural traditions of self, and thus obtain release from reincarnation.
India I he Jains, although a small minority (less Fasting may last many years consisting of gradual
• han 1% of the population) are an important pres- reduction in the intake of nutrition, and “the aspi
<-'0'/; jd the mosaic of Indian culture, and share the rant is taken through a series of fifteen intermediate
Hindu concept of the good or dignified death as one observances leading to the pratyakhyana or complete
•bat )■; marked, above all, by the dying person being abstinence from every kind of intake, save air”
in full control of the happening. Their view of how [20, p. 39].
Jain ethics teaches that when a householder
’his may be achieved, and their interpretation of it
believes
that death is near because of incurable
however, radically different from the general
disease or old age, or fears death at the hands of
Hindu standpoint.
_, 2n appropriate
method of abandoning
an enemy,
an
■/(Jin lradii ion
one’s body should be chosen. Death is not desired,
Jainism predates post-vcdic Hinduism by many because it is at hand, nor feared for one can still
^niurics and the latter derives some of its key be one’s own master. One must not lose control.
motifs from Jainism and Buddhism including, When an aspirant finally sits down to die, he must
notably, the ideas of ahimsa (non-killing or, more choose the time, place, body posture, etc. with great
care, for these must remain unchanged until the
generally, non-violence) and nirvana (liberation).
I he inner/outer-sclf dichotomy of Hinduism men- moment of death. The second main Jain sect of
lioncd above appears as a much sharper opposition, Shvetambaras also subscribe to a similar notion of
but ihe physical body is still not wholly rejected, living and dying with dignity.t
Needless to say, the numbers of those who choose
at the outset as it were, so that suicide is considered
an act lacking in merit. It contradicts the value of to die thus, considering it the most dignified death,
is small, though it may have been proportionately
larger in ancient times: epigraphical and archaeolog
* • li' noiion of meaningless death in the sense implied here ical evidence lends support to such a belief. But
>nay he found in many cultures. Thus Elias, writing death through fasting is not unknown among Jains
• i<im the perspective of western culture, observes: “It is and Hindus even in contemporary times.
• ' iiihlc when people die young before they have been
The best known fairly recent example is that of
al»l«- to give their lives a meaning and taste the joys of
Vinoba Bhave, Mahatma Gandhi’s most distin
•'•< “ |6, p. 66|.
11 d<- ihe Jains, the Buddhists too have a highly developed guished non-political disciple. In 1983, when he was
hadiiion of 'meditations' on death, but they are an even in his late eighties, he suffered a h^art attack. He
•uiallci component of the Indian population than the refused medication, despite the best efforts of every
lam-. However, an excellent account of this subject is body concerned, including the Prirhe Minister of
avaihhlc in respect of Tibetan Buddhists drawing upon,
among other sources, the famous “Tibetan Book of the India, and within a few days he Abstained from
■ ), a<l' |2?.|. Needless to add. the Buddhists generally, like nourishment also. Soon afterwards, j he died in his
•hr lams and Hindus, do not look upon death as the hermitage, on the eve of the Hindu festival ol lights
• ni-my or destruction of life. At the same time, they do (Deepavali), a very auspicious occasion in the Hindu
"••i approve of self mortification or other procedures of calendar. His passing was, in terms if the tradition.
nn limp' death

Dying with dignity

is of the F
typology of (:: oeaih,
>roadly grouped
* -- inta
second. •- ise death;
ise deaths’
de falls in die
lay be a .oonsciousjj
T It is marred
s well as 'lolence.
however,• tiat the
d f
ntual death for a
it to belong to the
wise deaths*',
There
chieving it. such _
as
meditation. knouT
Uekhana). Before a
uch austerities, he
■hat the outer-body
er-self (aima) and.
body is the best
arma that remains
• cleanse the inner
om r'‘:-'carnation.
isisti.
,f gradual
m, and “the aspifteen intermediate
hyana or complete
intake, save air”
i a householder
use of incurable
at the hands of
J of abandoning
th is not desired,
for one can still
not lose control.
to die, he must
e, etc. with great
anged until the
tin Jain sect of
imilar notion of
lose who choose
dign' ' death,
prop .lOnately
ind archaeologi a belief. But
n among Jains
mes.
nple is that of
’ most distin\ when he was
art attack. He
Torts of everye Minister of
bstained from
ie died in his
itival of lights’
i in the Hindu
the tradition.

paradigmatic death, surcharged with dignity—
' joed an extraordinary thing. As may have been
l,U .ctcd, some English language newspapers comCV-nted editorially that the doctors who let this death
pj1 pen were guilty of unprofessional conduct, and
that such deaths should not be countenanced in
ordinary life.
4. CONCLUDING REMARKS

Dying and death are part and parcel of human life.
In modern society, which is the actual or desired
social condition of our times, one does not anticipate
one’s death any more than one can anticipate one’s
birth, but one does live under the shadow of death.
This shadow covers more and more adult lives as
life-expectancy increases among all peoples. The ex
panding diagnostic abilities of modern medicine
make death a constant presence, particularly in the
lives of the elderly, and generate a dependence on
specialists and technological intervention. Increas
ingly one is infantalized and finds oneself incapable
of describing, and to a great extent understanding,
one’s condition. One becomes metaphorically, and
even literally, speechless. Isolated, taken over by
specialists, bound to machines, one feels not only
lonely but even remorseful and guilty (if only I had
taken these symptoms seriously, if only I had not
done those things ...). One loses both one’s freedom
and one’s dignity.
Freedom and dignity are, of course, cultural
constructs. While the ideas are universal, their
precise content admits of cultural variability. Indeed,
this can go very far as is evidenced by B. F. Skinner’s
attack on them as antiquated, futile and even harmful
ideas in the context of modern society where every
thing, or almost everything, can be fixed, by designing
cultural practices in an appropriate manner [23].
However, those who still see some virtue in these
ideas, will find it remarkable how across many cul
tures (and not only in Christian, Hindu and Jain
cultural traditions) loss of autonomy, and loss
of control over oneself in the context of death,
are seen to result in undignified death, that is death
which lacks nobility, distinction and illustriousness.
Drawing upon half a dozen cultures from distant
parts of the world, Jonathan Parry and Maurice
Bloch observe that the ‘good’ (we might say the
’dignified’) death is “one which suggests some degree
of mastery over the arbitrariness of the biological
occurrence” [24, p. 15]. I have tried to show in this
paper that modern medical and legal procedures
increase, perhaps paradoxically, the range of this
arbitrariness. What is arbitrariness from the victim’s
perspective is power from the perspective of those
who control others with the help of specialized
knowledge. As Foucault has pointed out, various
mechanisms of power have in the last 200 years
established their control over the body in both its
living and dead states [3, 25, 26].

431

In drawing attention to traditional Hindu and
Jain views of death and dying, which have some
points in common with the Christian view, I am not
suggesting that all one has to do to restore dignity
to death is to make a turn-about and proceed
from modernity towards tradition. The point of the
comparison very briefly undertaken here is that
the so-called modern attitudes instead of being held
in stark opposition to the traditional can have
their excesses corrected by a recognition of alterna
tive perspectives, whether traditional or themselves
modern.
One of the central ideas from the traditional per
spectives, with which I will conclude this paper, is
that which does not oppose life and death in stern
opposition, reserving dignity, if at all for anything,
for the former, and consigning the latter to utter
meaninglessness. The words of the fourteenth century
Kashmiri Pandit mystic poetess, Lalla,
Alike for me is life and death:
Happy to live and happy to die,
I mourn for none, none mourns for me!
were echoed 500 years later by Walt Whitman:
Have you supposed it beautiful to be born?
I tell you I know it is just as beautiful to die!
These words call our attention to the value of holism
in the midst of fragmentation that characterizes
modern life everywhere, valorising life in instrumen
tal terms and designating death an indignity.

REFERENCES

1. Krishnamurti J. Last Talks at Sanen 1985. Harper and
Row, San Francisco, 1986.
2. Aries, Phillipe. The Hour of Our Death. Alfred Knopf,
New York, 1981.
3. Foucault M. The Birth of the Clinic: An Archaeology of
Medical Perception. Tavistock, London, 1976.
4. Gerth H. H. and Mills C. W. (Eds) From Max Weber:
Essays in Sociology. Routledge and Kegan Paul,
London, 1948.
5. Illich I. Medical Nemesis: The Exploration of Health.
Rupa, Delhi, 1975.
6. Elias N. The Loneliness of Dying. Blackwell, Oxford,
1985.
7. Myerhoff B. Number Our Days. D. P. Dutton, New
York, 1979.
8. Moller D. W. On Dying without Dignity: The Human
Impact of Technological Dying. Baywood, New York,
1990.
9. Nandy A. (Ed.) Science, Hegemony and Violence: A
Requiem for Modernity. Oxford University Press, Delhi,
1988.
10. Thomasma D. C. and Graber G. C. Euthanasia: Toward
an Ethical Social Policy. Continuum, New York,
1990.
11. Dworkin R. The right to death. The New York \Review
of Books, p.p. 14-17, 1991.
12. Humphry D. The Final Exit. The Hemlock Society,
1991.
13. Bowker J. The Meanings of Death. Cambridge Univer
sity Press, Cambridge, 1991.
14. Mascaro J. The Bhagavad Gita. Penguin Books, Harmondsworth, 1962.

432
15. Radhakrishnan S. The Principal Upanishads. Allen and
Unwin, London, 1953.
16. Mehta J. L. Problems of understanding. Bull. Centre
Study World Religions 15, 2-12, 1988/89.
17. Madan T. N. Living and dying. In Non-Renunciation:
Themes and Interpretations of Hindu Culture. Oxford
University Press, New Delhi, 1987.
18. Parry J. P. Death and cosmogony in Kashi. Contri
butions Ind. Sociol. 15, 337-365, 1981.
19. Weber M. The Religion of India: The Sociology of
Hinduism and Buddhism. The Free Press, Glencoe, IL,
1958.
20. Shettar S. Inviting Death: Historical Experiments
on Sepulchral Hill. Karnatak University, Dharwad,
1986.

21. Shettar S. Pursuing Death: Philosophy and Practice of
Voluntary Termination of Life. Karnatak University,
Dharward, 1990.
22. Mullin G. H. Death and Dying: The Tibetan Tradition.
Arkana, Boston, 1986.
23. Skinner B. F. Beyond Freedom and Dignity. A. Knopf,
regeneration of life. In Death and Regeneration of Life.
Cambridge University Press, Cambridge, 1982.
25. Foucault M. Discipline and Punish: The Birth of the
Prison. Allen Lane, London, 1977.
26. Armstrong D. Political Anatomy of the Body: Medical
Knowledge in Britain in the Twentieth Century. Cam
bridge University Press, Cambridge, 1983.

i *

i
■

**'/

PERSONAL VIEW
Greed and the medical profession
Ralph Crawshaw

rganised medicine is not giving
1 proper attention to the disturbing
presence in the profession of a uni
versal human trait: greed. Perhaps doctors’
greed is less of a problem in Britain where an
estimated 70% of the doctors are generalists,
and reimbursement in the main is controlled
by the national health system. Not so in the
United States where 70% of doctors are
specialists and an open health care market
allows doctors to charge “reasonable and
customary” fees. This is interpreted by some
as “all the traffic will bear.”
Despite considerable evidence at the other
end of the generosity scale that 64% of US

postulated by the editoc of JAMA, Dr every medical action, an ethic df greed
George Lundberg. Heuristically he divides changes our elemental belief that the buyer is
the profession into four categories along a always responsible. With an ethic of greed
continuum of reimbursement, starting with doctors cease to base their motivation on
altruistic missionaries, moving to profes
compassion and caring to become merchants
sionals, then business people, and finally selling medical services to the highest bidder.
money grubbers. The professional and busi
Given these reasons for concern the first
ness people form the vast majority under the and essential action for the profession is to
curve. The money grubbers, the greedy undertake an open discussion of the problem.
ones, occupy about 3-5% of the area. Three The consequences of continued side stepping
per cent seems a fair beginning for consider
by the profession of the prpblem of its greedy
ing those within the profession for whom
members is loss of authority, autonomy, and
“greed has become too dominant an ethic.”
honour. The erosion of the profession’s
Some still ask, “What is the importance of position of respect with the public is clear.
the problem;, greed among human beings is Further erosion will aggravate all the
as common as fleas among dogs?” For the
medical profession greed presents three
fundamental problems.
“The income ofspecialty stars
Firstly, greed compromises quality of care.
“The most corrosive effect of
An egregious example is in the case of
raises insurance premiums
greed. ..is to the profession’s
a doctor in the US whose yearly income
for all insured patients.”
exceeds $4m. laterally busloads of patients
philosophy ofservice.
from nursing homes arrive at this doctor’s
office and without a sham of a physical
examination undergo a surgical procedure
doctors give away considerable amounts of with the postoperative care left entirely to a
problems which now diminish tfie deliyerj'’ of
free service there is no end of opinion,
nurse.
health care while blurring the moral goal of
verging on explicit protest, from patients,
Secondly, greed limits access to care foi
the profession.
their families, insurance operators, legis
poor patients. The income of specialty stars
Without question doctors should earn in
lators, and the general public that doctors are raises insurance premiums for all insured
a greedy lot. In my opinion, which I discover patients. As the premiums go up increasing comes which genuinely reflect the training,
time, effort, and trust that goes with their
I must leave my native land to voice, it
numbers of citizens with marginal incomes care of the sick. It is malignantly counter
w uwumuvc
behoves the medical profession to address are forced to lorgo
insurance coverage; their productive for soaring medical reimburse
any problem vexing its relationship with access to health ca^ evaporates.'
ment to diminish the stature of the vast
the public. Doctors’ greed is just such a
Examples of greed can be found in all majority of doctors.
troubling problem.
specialties. Imagine a hospna’ in a small city
It is imperative for the medical profession
The profession is aware that greed best considering opening a service to* coronary
to open its published journals and collegial
describes how some of its members place
bypass operations. To secure a thoracic forums to a candid appraisal of the existence
profit before patient wellbeing. Before
surgeon the hospital board is prepared to
addressing the 1991 annual meeting of the offer a base assured income beginning at of greed in its ranks. There is no need, in fact
there u danger of exaggeration and mindless
Federation of State Medical Boards of the
81'25m a year, including full office support.
United States I asked the solons of the Simultaneously, the area suffers from a lack regulation, toi the discussion to be taken up
by the media. This is nnt to imply the
profession to indulge me by responding
of family practitioners, who, at best, can discourse should be secretive but that ;t
directly to a question. “Do you believe
expect to make $80000 to $100000 a year should have the serious attention and
the medical profession has a problem with without any office support.
encouragement of the leaders of organised
greed?” Out of approximately 150, 90%
Consider my city of Portland, Oregon. It medicine, including the editors of all
raised their hands in assent.
has one hospital offering organ transplant specialty journals, to insure a scholarly and
ihe US medical profession as a whole
services and two other “non-profit” hospitals objective appraisal. The discussion should
nevertheless seems hesitant to move beyond planning
nlonnmrt
r'z-wv**** a
.i
ah
competitive ----------•
three •
services. All
acknowledging the greed problem and to hospitals expect to offer high if not exorbitant strive to determine objectively sane and
comment on its scale. The profession has a staff incomes ultimately to come out of the prudent limits for medical reimbursement,
but not be confrontational, nittinv
pitting one
curious propensity to avoid the issue by
extsttng health insurance pool that makes no doctor against another, one specialty ag;
;ainst
relegating possible doctor greed to the status
provision for the health care of the homeless,
another. Those that exceed considered li
of a non-problem. The subject seldom, if
An editorial in the local newspaper labels this should no longer have the tacit approval of
ever, appears in professional journals. The health care business at its worst, “greedthe majority, the 97% who do not let a desire
side stepping is accomplished by labelling
driven nonsense.”
for money determine their service to the
any focused concern about greed as doctor
Thirdly, the most corrosive effect of greed sick. Clearly, a serious problem with an
bashing and thus beneath the profession’s
and the tacit approval of greed is to the
purview.
exaggerated and misanthropic human trait,
profession’s philosophy of service. Where greed, challenges the medical profession to
Little data exist for doctor greed. One
most of us were trained to believe that our move to higher moral ground in the care of.
rough approximation of the problem is
service is based solely on trust, with firstly the sick. Ralph crawshaw
is a professor of
implied in a bell curve for docrors’ incoi
avoiding harm as the ultimate measure of psychiatry in Portland, Oregon
I

*

SELECTIONS EROM BMJ

il ROM BMJ VOL. 306 9 JANUARY IWJ. 151)
VOL. 9

MARCH 1993

95

--------- \

---------------

PERSONAL VIEW
Greed and the medical profession
Ralph Crawshaw

rganised medicine is not giving
1 proper attention to the disturbing
presence in the profession of a uni
versal human trait: greed. Perhaps doctors’
greed is less of a problem in Britain where an
estimated 70% of the doctors are generalists,
and reimbursement in the main is controlled
by the national health system. Not so in the
United States where 70% of doctors are
specialists and an open health care market
allows doctors to charge “reasonable and
customary” fees. This is interpreted by some
as “all the traffic will bear.”
Despite considerable evidence at the other
end of the generosity scale that 64% of US

I

-• f

postulated by the editor of JAMA, Dr
George Lundberg. Heuristically he divides
the profession into four categories along a
continuum of reimbursement, starting with
altruistic missionaries, moving to profes
sionals, then business people, and finally
money grubbers. The professional and business people form the vast majority under the
curve. The money^
—l-1— the
■'
i-------- grubbers,
greedy
ones, occupy about 3-5% of
the area.
Three
-- --— T*.—j
»ent Seei?s a
beginning for considering those within the profession for whom
“greed has become too dominant an ethic.”
Some still ask, “What is the importance of
the problem; greed among human beings is
as common as fleas among dogs?” For the

every medical action, an ethic of greed
changes our elemental belief that the buyer is
always responsible. With an ethic of greed
doctors cease to base their motivation on
compassion and caring to become merchants
selling medical services to the highest bidder.
Given these reasons for concern uthe first
and essential action for* the professioj
i is to
undertake an open discussion of the problem.
The consequences of continued side stepping
by the profession of the problem of its greedy
members is loss of authority, autonomy, and
honour. The erosion of the profession’s
position of respect with the public is (clear.
Further
r___L„r erosion will aggravate all the

medical profession greed pr
fundamental problems.
"The income ofspecialty stars
Firstly, greed compromises quality of care.
"The most corrosive effect of
raises insurance premiums An egregious example is in the case of greed. ..is to the profession^
a doctor in the US whose yearly income
for all insured patients.”
exceeds S4m. Literally busloads of patients
philosophy ofservice.
from nursing homes arrive at this doctor’s
office and without a sham of a physical
examination undergo a surgical procedure
doctors give away considerable amounts of with the postoperative care left entirely to a
problems which now diminish t^e delivery’of
free service there is no end of opinion,
nurse.
health care while blurring the moral gbal of
verging on explicit protest, from patients,
Secondly, greed limits access to care for
the profession.
their families, insurance operators, legis
poor patients. The income of specialty stars
Without question doctors should earjn in
lators, and the general public that doctors are raises insurance premiums for all insured
’ ’ genuinely reflect the training,
a greedy lot. In my opinion, which I discover patients. As the premiums go up increasing comes 'which
time, effort, and trust that goes with
__1 their
I must leave my native land to voice, it
numbers of citizens with marginal incomes
behoves the medical profession to address are forced to forgo insurance coverage; their care of the sick. It is malignantly counterproductive for soaring medical reimburse
any problem vexing its relationship with access to health care evaporates.
ment to diminish the stature of the vast
the public. Doctors’ greed is just such a
Examples of greed can be found in all majority of doctors.
troubling problem.
specialties. Imagine a hospital in a small city
It is imperative for the medical profession
The profession is aware that greed best
considering opening a service for coronary to open its published journals and collegial
describes how some of its members place bypass operations.
To secure a thoracic
forums to a candid appraisal of the existence
profit before patient wellbeing. Before
surgeon the hospital board is prepared to of greed in its ranks. There is no need, in fact
addressing the 1991 annual meeting of the offer a base assured income beginning at
. .
„ cc there danger of exaggeration and mindless
Federation of State Medical Boards of the 81-25m a j
’ * " w full
“ “ office suppon.
year,. including
regulation, for the discussion to be taken up
^nited States I asked the solons of the Simultaneously,
het by the media. This is not to imply the
ouslv. the area suffers from a» lack
profession to indulge me by responding of family practitioners, who, at best, can
discourse should be secretive but th$it it
directly to a question. “Do you believe
expect to make S80000 to SI00000 a year should have the serious attention and
the medical profession has a problem with
without any office suppon.
encouragement of the leaders of organised
greed?” Out of approximately 150, 90%
Consider my city of Portland, Oregon. It medicine, including the editors of all
raised their hands in assent.
has one hospital offering organ transplant specialty journals, to insure a scholarly and
lhe US medical profession as a whole
services and two other “non-profit” hospitals
objective appraisal. The discussion should
nevertheless seems hesitant to move Ibeyond planning competitive services. All three
acknowledging the greed problem and to hospitals expect to offer high if not exorbitant strive to determine objectively sane and
comment on its scale. The profession has a staff incomes, ultimately to come out of the prudent limits for medical reimbursement,
but not be confrontational, pitting one
curious propensity to avoid the issue by
existing health insurance pool that makes no doctor against another, one specialty against
relegating possible doctor greed to the status
provision for the health care of the homeless.
another. Those that exceed considered limits
of a non-problem. The subject seldom, if
An editorial in the local newspaper labels this should
loncrpr have
hav#» the tmit
should no longer
tacit approval1 of
ever, appears in professional journals. The health care business at its worst, “greedf’
’ ' . the
' 97%
—' who do
2___________
the majority,
not let a desire
side stepping is accomplished by labelling
driven nonsense.”
for money determine their service to the
any focused concern about greed as doctor
Thirdly, the most corrosive effect of greed sick. Clearly, a serious problem with
bashing and thus beneath the profession’s
an
and the tacit approval of greed is to the
purview.
and misanthropic human trait.
exaggerated
-----------------------------------....uuiiuuvpiv
LLilJL,
profession’s philosophy of service. Where greed, challenges the medical profession to
Little data exist for doctor greed. One
most of us were trained to believe that our move to higher moral ground in the car: of
rough approximation of the problem is
service
avr.i/jjr.r.is based solely
' on
i . trust,
'' with firstly
the sick,
is a professor of
crawshaw
ralph
crawshaw
sick.—ralph
implied in a bell curve for doctors’ incomes
avoiding harm as the ultimate measure of psychiatry
~
.
in Portland,
Oregon
SELECTIONS FROM BMJ

il ROM BMJ VOL. 306 9 JANUARY 1993, 151)
VOL. 9

MARCH 1993

95

-I

PERSONAL VIEW
■

I

Greed and the medical profession
Ralph Crawshaw

rganised medicine is not giving postulated by the editot of JAMA, Dr
l
every medical action, an ethic of greed
- ’
1 proper attention to the disturbing
George Lundberg. Heuristically he divides changes our elemental belief that the buyer is
presence in the profession of a uni
the profession into four categories along a f’
......................
__
versal human trait: greed. Perhaps doctors’ continuum of reimbursement, starting with always responsible. With an ethic of greed
doctors
cease
to
base
their
motivation__
greed is less of a problem in Britain where an altruistic missionaries, moving to profes
estimated 70% of the doctors ace generalists, sionals, then business people, and finally compassion and caring to become merchants
selling medical services to the highest bidder.
and reimbursement in the main is controlled
money grubbers. The professional and busi
Given these reasons for concern the first
by the national health system. Not so in the
ness people form the vast majority under the and essential action for the profession is to
United States where 70% of doctors are
curve. The money grubbers, the greedy undertake an open discussion of the problem.
specialists and an open health care market
ones, occupy about 3-5% of the area. Three The consequences of continued side stepping
allows doctors to charge “reasonable and
per cent seems a fair beginning for consider
by the profession of the problem of its greedy
customary” fees. This is interpreted by some ing those within the profession for whom
members is loss of authority, autonomy , and
as “all the traffic will bear.”
“greed has become too dominant an ethic.”
_____
_____
honour.
The_ erosion of UIV
the piu
profession’s
Despite considerable evidence at the other
Some^still ask, What is the importance of position of respect with the public: is plear.
end of the generosity scale that 64% of US the problem; greed among human beings is
Further erosion will aggravate all the
as common as fleas among dogs?” For the
medical profession greed presents three
fundamental problems.
"The income ofspecialty stars
Firstly, greed compromises quality of care.
"The most corrosive effect of
An
egregious example is in the case of
raises insurance premiums
greed. ..is to the profession^
a doctor in the US whose yearly income
for all insured patients.”
exceeds $4m. Literally busloads of patients
philosophy ofservice."
from nursing homes arrive at this doctor’s
office and without a sham of a physical
examination undergo a surgical procedure
doctors give away considerable amounts of with the postoperative care left entirely to a
problems which now diminish t]ie delivery of
free service there is no end of opinion,
nurse.
health care while blurring the moral goal of
verging on explicit protest, from patients,
Secondly, greed limits access to care foi
the profession.
their families, insurance operators, legis- poor patients? The income of specialty
j stars
Without question doctors should earn in
lators, and the general public that doctors are raises insurance premiums for all insured
comes
which genuinely reflect the training,
a greedy lot. In my opinion, which I discover patients. As the premiums go up increasing
time, effort, and trust that goes with their
I must leave my native land to voice, it numbers of citizens with marginal incomes
behoves the medical profession to address are forced to forgo insurance coverage; their care of the sick. It is malignantly counter
productive for soaring medical reimbuirseany problem vexing its relationship with access to health care evaporates.
ment to diminish the stature of the •vast
the public. Doctors’ greed is just such a
Examples of greed can be found in all majority of doctors.
troubling problem.
specialties. Imagine a hospital in a small city
It is imperative for the medical profession
The profession is aware that greed best considering opening a service for coronary
to open its published journals and collegial
describes how some of its members place bypass operations. To secure a thoracic
forums to a candid appraisal of the existence
profit before patient wellbeing. Before
surgeon the hospital board is prepared to
addressing the 1991 annual meeting of the offer a base assured income beginning at of greed in its ranks. Tliere is no need, in fact
there is danger of exaggeration and mindless
Federation of State Medical Boards of the
$l'25m a year, including full office support.
United States I asked the solons of the Simultaneously, the area suffers from a lack regulation, for the discussion to be taken up
by the media. This is not to imply the
profession to indulge me by responding
of family practitioners, who, at best, can discourse should be secretive but that it
directly to a question. “Do you believe
expect to make 880000 to 8100 000 a year should have the serious attention hnd
the medical profession has a problem with
without any office support.
(encouragement of the leaders of organised
greed?” Out of approximately 150, 90%
Consider my city of Portland, Oregon. It imedicine, including the editors of all
raised their hands in assent.
has one hospital offering organ transplant ’specialty journals, to insure a scholarly and
The US medical profession as a whole
services and two other “non-profit” hospitals <
appraisal. The discussion should
nevertheless seems hesitant to move beyond planning competitive services. All three objective
«
strive
to determine objectively sane and
acknowledging the greed problem and to
hospi tals expect to offer high if not exorbitant
comment on its scale. The profession has a staff incomes, ultimately to come out of the prudent limits for medical reimbursement,
but not be confrontational, pitting )ne
curious propensity to avoid the issue by
existing health insurance pool that makes no doctor against another, one specialty aga nst
relegating possible doctor greed to the status
provision for the health care of the homeless.
another. Those that exceed considered limits
of a non-problem. The subject seldom, if
An editorial in the local newspaper labels this should no longer have the tacit approval
of
ever, appears in professional journals. The health care business at its worst, “greedthe majority, the 97% who do not let a desire
side stepping is accomplished by labelling
driven nonsense.”
for money determine their service to the
any focused concern about greed as doctor
Thirdly, the most corrosive effect of greed sick. Clearly, a serious problem with
an
bashing and thus beneath the profession’s
and the tacit approval of greed is to the exaggerated and misanthropic human triit,
purview.
profession’s philosophy of service. Where greed, challenges the medical profession to
Little data exist for doctor greed. One
most of us were trained to believe that our move to higher moral ground in the care of.
rough approximation of the problem is
service is based solely on trust, with firstly the
.... sick.—ralph
crawshaw
is a professor of
implied in a bell curve for doctors’ incomes
avoiding harm as the ultimate measure of psychiatry■ m Portland, Oregon
i

r?

&

SELECTIONS FROM BMJ

il ROM BMJ VOL. 306 9 JANUARY 1993,
VOL. 9

MARCH 1993

51)

95

4-

PERSONAL VIEW
Greed and the medical profession
Ralph Crawshaw

rganised medicine is not giving
1 proper attention to the disturbing
presence in the profession of a uni
versal human trait: greed. Perhaps doctors’
greed is less of a problem in Britain where an
estimated 70% of the doctors are generalists,
and reimbursement in the main is controlled
by the national health system. Not so in the
United States where 70% of doctors are
specialists and an open health care market
allows doctors to charge “reasonable and
customary” fees. This is interpreted by some
as “all the traffic will bear.”
Despite considerable evidence at the other
end of the generosity scale that 64% of US

postulated by the editor of JAMA, Dr every medical action, an ethic of lgreed
- -George Lundberg. Heuristically he divides changes our elemental belief that the buyer is
the profession into four categories along a always responsible. With an ethic of greed
continuum of reimbursement, starting with doctors cease to base their motivation __
on
altruistic missionaries, moving to profes
compassion and caring to become merchants
sionals, then business people, and finally selling medical services to the highest bidder.
money grubbers. The professional and busi
Given these reasons for concern the first
ness people form the vast majority under the and essential action for the profession is to
curve. The money grubbers, the greedy undertake an open discussion of the problem.
ones, occupy about 3-5% of the area. Three The consequences of continued side stepping
per cent seems a fair beginning for consider
by the profession of the problem of its gjreedy
ing those within the profession for whom
members is loss of authority, autonomy, and
“greed has become too dominant an ethic.”
honour. The erosion of the profession’s
Some still ask, “What is the importance of position of respect with the public is clear.
the problem; greed among human beings is Further erosion will aggravate all the
as common as fleas among dogs?” For the
medical profession greed presents three
- ------------------------------------1__ 7
fundamental problems.
“The income ofspecialty stars
Firstly, greed compromises quality of care.
“The most corrosive effect of
An egregious example is in the case of
raises insurance premiums
greed ...is to the profession^
a doctor in the US whose yearly income
for all insured patients. ”
exceeds 84m. Literally busloads of patients
philosophy ofservice. ”
from nursing homes arrive at this doctor’s
office and without a sham of a physical
examination undergo a surgical procedure
doctors give away considerable amounts of with the postoperative care left entirely to a
problems which now diminish t]ie deliyery of
free service 'here is no end of opinion,
nurse.
health care while blurring the moral goal of
verging on explicit protest, from patients,
Secondly, greed limits access to care foi
the profession.
their families, insurance operators, legis
poor patients. The income of specialty stars
Without question doctors should earn in
lators, and the general public that doctors are raises insurance premiums for all insured ........
comes.............
which genuinely reflect the trailing,
a greedy lot. In my opinion, which I discover patients. As the premiums go up increasing time, effort, and
, ffort, and trust that goes with their
I must leave my native land to voice, it
numbers of citizens with marginal incomes
behoves the medical profession to address are forced to forgo insurance coverage; their care of the sick. It is malignantly counter
productive for soaring medical reimburse
any problem vexing its relationship with access to health care evaporates.
ment to diminish the stature of the vast
the public. Doctors’ greed is just such a
Examples of greed can be found in all majority of doctors.
troubling problem.
specialties. Imagine a hospital in a small city
It is imperative for the medical profession
The profession is aware that greed best considering opening a service for coronary
to open its published journals and collegial
describes how some of its members place bypass operations. To secure a thoracic
forums to a candid appraisal of the existence
profit before patient wellbeing. Before
surgeon the hospital board is prepared to
addressing the 1991 annual meeting of the offer a base assured income beginning at of greed in its ranks. There is no need, iri fact
there is danger of exaggeration and mindless
Federation of State Medical Boards of the 81-25m a j
'
____
year, including
full‘ office
support, regulation, for the discussion to be take.
United States I asked the solons of the Simultaneously, the area suffers from {Hack
by the media. This is not to imply the
profession to indulge me by responding
of family practitioners, who, at best, can discourse should be secretive but that it
directly to a question. “Do you believe
expect to make 580000 to 8100000 a year should have the serious attention and
the medical profession has a problem with without any office support.
encouragement of the leaders of organised
greed?” Out of approximately 150, 90%
Consider my city of Portland, Oregon. It medicine, including the editors of
all
raised their hands in assent.
has one hospital offering organ transplant specialty journals, to insure a scholarly and
’
•
•
The US medical profession as a whole cservices
and two other “non-profit” hospitals objective appraisal, The discussion should
nevertheless seems hesitant to move beyond planning
a 11
nlanninrr r-rtmna*
:___
competitive _____
services.
All
three * ■
acknowledging the greed problem and to hospitals expect to offer high if not exorbitant strive to determine objectively sane and
comment on its scale. The profession has a staff incomes, ultimately to come out of the prudent limits for medical reimbursement,
but not be confrontational, pitting one
curious propensity to avoid the issue by
existing health insurance pool that makes no doctor against another, one specialty against
relegating possible doctor greed to the status
provision for the health care of the homeless. another. Those that exceed considered limits
of a non-problem. The subject seldom, if
An editorial in the local newspaper labels this should no longer have the tacit approval of
ever, appears in professional journals. The health care business at its worst, “greedthe majority, the 97% who do not let a desire
side stepping is accomplished by labelling
driven nonsense.”
for money determine their service to the
any focused concern about greed as doctor
Thirdly, the most corrosive effect of greed sick. Clearly, a serious problem with
bashing and thus beneath the profession’s
an
and the tacit approval of greed is to the
purview.
exaggerated and misanthropic human trait,
profession’s philosophy of service. Where greed, challenges the medical professioi
Little data exist for doctor greed. One
to
most of us were trained to believe that our move to higher moral ground in the cari of.
rough approximation of the problem ia
is service is based solely on trust, with firstly
the
sick.—
is
professoi
of
a
ralph
crawshaw
implied in a bell curve for doctors’ incomes
avoiding harm as the ultimate measure of psychiatry in Portland, Oregon
I

SELECTIONS FROM BMJ

(I ROM BMJ VOL. 306 9 JANUARY 1993, 151)
VOL. 9

MARCH 1993

95

J_

PERSONAL VIEW

Greed and the medical profession
Ralph Crawshaw

rganised medicine is not giving
1 proper attention to the disturbing
presence in the profession of a uni
versal human trait: greed. Perhaps doctors’
greed is less of a problem in Britain where an
estimated 70% of the doctors are generalists,
and reimbursement in the main is controlled
by the national health system. Not so in the
United States where 70% of doctors are
specialists and an open health care market
allows doctors to charge “reasonable and
customary” fees. This is interpreted by some
as “all the traffic will bear.”
Despite considerable evidence at the other
end of the generosity scale that 64% of US

postulated by the editor of JAMA, Dr every medical actioii, an ethic of greed
George Lundberg. Heuristically he divides changes our elemental belief that the buyer is
the profession into four categories along a always responsible. With an ethic of greed
continuum of reimbursement, starting with doctors cease to base their motivation on
altruistic missionaries, moving to profes
compassion and caring to become merchants
sionals, then business people, and finally selling medical services to the highest bidder.
fnoney grubbers. The professional and busi
Given these reasons for concern the first
ness people form the vast majority under the and essential action for the profession is to
curve. The money grubbers, the greedy undertake an open discussion of the problem.
ones, occupy about 3-5% of the area. Three The consequences of continued side stepping
per cent seems a fair beginning for consider
by the profession of the problem of its greedy
ing those within the profession for whom members is loss of authority, autOnornj), and
“greed has become too dominant an ethic.”
honour. The erosion of the profession’s
Some still ask, “What is the importance of position of respect with the public is clear,
the problem; greed among human beings is Further erosion will aggravate all the
as common as fleas among dogs?” For the
medical profession greed presents three
fundamental problems.
((The income ofspecialty stars
Firstly, greed compromises quality of care.
“The most corrosive effect of
An
egregious example is in the case of
raises insurance premiums
greed. ..is to the profession^
a doctor in the US whose yearly income
for all insured patients.”
exceeds $4m. Literally busloads of patients
philosophy ofservice.”
from nursing homes arrive at this doctor’s
office and without a sham of a physical
examination undergo a surgical procedure
doctors give away considerable amounts of with the postoperative care left entirely to a
problems which now diminish tjie delivery' of
free service there is no end of opinion,
nurse.
health
care while blurring the moral goal of
verging on explicit protest, from patients,
Secondly, greed limits access to care for
the profession.
their families, insurance operators, legis
poor patients. The income of specialty stars
Without question doctors should earn in
lators, and the general public that doctors are raises insurance premiums for all insured
comes
which genuinely reflect the training,
a greedy lot. In my opinion, which I discover patients. As the premiums go up increasing
time, effort, and trust that goes with their
I must leave my native land to voice, it
numbers of citizens with marginal incomes care of the sick. It is malignantly counter
behoves the medical profession to address are forced to forgo „.auiauvc
insurance coverage; their productive for soaring medical reimburse
any problem vexing its relationship with access to health care evaporates,
ment to diminish the stature of the vast
the public. Doctors’ greed is just such a
"
Examples of greed can be found in all majority of doctors.
troubling problem.
specialties. Imagine a hospital in a small city
It is imperative for the medical profession
The profession is aware that greed best considering opening a service for coronary
to open its published journals and collegial
describes how some of its members place bypass operations. To secure a thoracic
profit before patient wellbeing. Before surgeon the hospital board is prepared to forums to a candid appraisal of the existence
addressing the 1991 annual meeting of the offer a base assured income beginning at of greed in its ranks. There is no need, in fact
there is danger of exaggeration and mindless
Federation of State Medical Boards of the $1-251113!
‘
"____
year, including
full office
support, regulation, for the discussioni to be taken up
United States I asked the solons of the Simultaneously, the area suffers from a lack
by the media. This is not to imply the
profession to indulge me by responding
of family practitioners, who, at best, can discourse should be secretive but that it
directly to a question. “Do you believe
expect to make S80000 to 8100000 a year should have
attention and
- - the
—- serious
~
the medical profession has a problem with without any office support.
encouragement of the leaders :of organised
greed?” Out of approximately 150, 90%
Consider my city of Portland, Oregon. It medicine, including the editors of all
raised their hands in assent.
has one hospital offering organ transplant specialty journals, to insure a scholarly and
The US medical profession as a whole s
'
■
services
and• two other
“non-profit” hospitals objectsive appraisal. The discussion should
nevertheless seems hesitant to move beyond planning
ah
nl'inninrr
A
.t
three * •
competitive
services. All
acknowledging the greed problem and to hospitals expect to offer high if not exorbitant strive to determine objectively sane and
comment on its scale. The profession has a staff incomes, ultimately to come out of the prudent limits for medical reimbursement,
but not be confrontational,
\ .pitting
"
J one
curious propensity to avoid the issue by
existing health insurance pool that makes no doctor against another, one specialty against
relegating possible doctor greed to the status
provision for the health care of the homeless.
another. Those that exceed considered limits
of a non-problem. The subject seldom, if
An editorial in the local newspaper labels this should no longer have the tacit approval of
ever, appears in professional journals. The health care business at its worst, “greedthe majority, the 97% who do not let a desire
side stepping is accomplished by labelling driven nonsense.”
for money determine their service to the
any focused concern about greed as doctor
Thirdly, the most corrosive effect of greed sick. Clearly, a serious problem with
an
bashing and thus beneath the profession’s
and the tacit approval of greed is to the exaggerated and misanthropic human trait,
purview.
profession’s philosophy of service. Where greed, challenges the medical profession to
Little data exist for doctor greed. One
most of us were trained to believe that our
rough approximation of the FaW.v«.
.a
problem is service is based solely on trust, with firstly move to higher moral ground in the care of.
crawshaw
the sick.—ralph
is a professor of
implied in a bell curve for docrors’ incomes
avoiding harm as the ultimate measure of psychiatry- in Portland, Oregon
I

SELECTIONS FROM BMJ

il ROM BMJ VOL. 306 9 JANUARY 1993, 151)

VOL. 9

MARCH 1993

95

PERSONAL VIEW

Greed and the medical profession
Ralph Crawshaw

I
rganised medicine is not giving
1 proper attention to the disturbing
presence in the profession of a uni
versal human trait: greed. Perhaps doctors’
greed is less of a problem in Britain where an
estimated 70% of the doctors are generalists,
and reimbursement in the main is controlled
by the national health system. Not so in the
United States where 70% of doctors are
specialists and an open health care market
allows doctors to charge “reasonable and
customary” fees. This is interpreted by some
as “all the traffic will bear. ”
Despite considerable evidence at the other
end of the generosity scale that 64% of US

postulated by the editor of JAMA, Dr every medical action, an ethic of greed
George Lundberg. Heuristically he divides changes our elemental belief that the buyer is
the profession into four categories along a always responsible. With an ethic of greed
continuum of reimbursement, starting with doctors cease to base their motivation on
altruistic missionaries, moving to profes
compassion and caring to become merchants
sionals, then business people, and finally selling medical services to the highest bidder.
fnoney grubbers. The professional and busi
Given these reasons for concern the first
ness people form the vast majority under the and essential action for the profession! is to
curve. The money grubbers, the greedy undertake an open discussion of the problem.
ones, occupy about 3-5% of the area. Three The consequences of continued side stepping
per cent seems a fair beginning for consider
by the profession of the problem of its gteedy
ing those within the profession for whom members is loss of authority, autonomy, and
“greed has become too dominant an ethic.”
honour. The erosion of the profession’s
Some still ask, “What is the importance of position of respect with the public is Clear.
the problem; greed among human beings is Further erosion will aggravate all the
as common as fleas among dogs?” For the
medical profession greed presents three
fundamental problems.
“The income ofspecialty stars
Firstly, greed compromises quality of care.
“The most corrosive effect of
egregious example is in the case of
raises insurance premiums An
a doctor in the US whose yearly income greed. ..is to the profession's
for all insured patients. ”
exceeds $4m. Literally busloads of patients
philosophy ofservice."
from nursing homes arrive at this doctor’s
office and without a sham of a physical
examination undergo a surgical procedure
doctors give away considerable amounts <of with the postoperative care left entirely to> a
problems which now diminish tjie deliyery of
free service there is no end of opinion, nurse.
health
care while blurring the moral goal of
verging on explicit protest, from patients,
Secondly, greed limits access to care foi the profession.
their families, insurance cr
‘
operators, legis- poor patients. The income of specialtyj stars
Without question doctors should earn in
lators, and the general public that doctors are raises insurance premiums for all insured
comes
which genuinely reflect the training,
a greedy lot. In my opinion, which I discover patients. As the premiums go up increasing time, effort,
and
.
—J trust that goes with their
I must leave my native land to voice, it numbers of citizens with marginal
incomes
w
———Care
Maw* sick. AV
care C«
of the
It is malignantly vwuiilvx
counter-—
behoves the medical profession to address are
U tO.£OrgO insurance coverage; their productive for soaring medical reimburse
any problem vexing its relationship with access to health care evaporates?
ment to diminish the stature of the vast
the public. Doctors’ greed is just such a
Examples of greed can be found in all majority of doctors.
troubling problem.
specialties. Imagine a hospital in a small city
It is imperative for the medical profession
The profession is aware that greed best considering opening a service for coronary
describes how some of its members place bypass operations. To secure a thoracic to open its published journals and collegial
profit before patient wellbeing. Before surgeon the hospital board is prepared to forums to a candid appraisal of the existence
addressing the 1991 annual meeting of the offer a base assured income beginning at of greed in its ranks. TTiere is no need, in fact
Federation of State Medical Boards of the $l*25m a year, including full office support. there is danger of exaggeration and mindless
United States I asked the solons of the Simultaneously, the area suffers from a lack regulation, for the discussion to be takeri up
profession to indulge me by responding of family practitioners, who, at best, can by the media. This is not to imply the
directly to a question. “Do you believe expect to make $80'000 to $100000 a year discourse should be secretive but that it
should have the serious attention and
the medical profession has a problem with without any office support.
encouragement of the leaders of organised
greed?” Out of approximately 150, 90%
Consider my city of Portland, Oregon. It medicine, including the editors of all
raised their hands in assent.
has one hospital offering organ transplant _r
J journals, to insure a scholarly pnd
specialty
The US medical profession as a whole services and two other “non-profit” hospitals objective
appraisal. The discussioni should
.
t
nevertheless seems hesitant to move beyond planning competitive services. All three
strive to determine objectively sane and
acknowledging the greed problem and to hospitals expect to offer high if not exorbitant prudent
limits
for medical
----------------J reimbursement,
comment on its scale. The profession has a staff incomes, ultimately to come out of the
but
not
be
confrontational,
pitting one
curious propensity to avoid the issue by existing health insurance pool that makes no
relegating possible doctor greed to the status provision for the health care of the homeless. doctor against another, one specialty against
of a non-problem. The subject seldom, if An editorial in the local newspaper labels this another. Those that exceed considered limits
ever, appears in professional journals. The health care business at its worst, “greed- should no longer have the tacit approval of
the majority, the 97% who do not let a desire
side stepping is accomplished by labelling driven nonsense.”
for money determine their service tb the
any focused concern about greed as doctor
Thirdly, the most corrosive effect of greed sick. Clearly,
,, a serious problem with an
bashing and thus beneath the profession’s and the tacit approval of greed is to the
exaggerated and misanthropic human trait,
purview.
profession’s philosophy of service. Where
Little data exist for doctor greed. One most of us were trained to believe that our greed, challenges the medical profession to
rough approximation of the problem is service is based solely on trust, with firstly move to higher moral ground in the care of.
w a professor of
implied in a bell curve for doctors’ incomes avoiding harm as the ultimate measure of the sick.—Ralph crawshaw
psychiain in Portland, Oregon
I

I
ft

r’

I

___ -__ ___ L

SELECTIONS FROM BMJ

tI ROM BMJ VOL. 306 9 JANUARY 1993, 151)
VOL. 9

MARCH 1993

95

I

I

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BMA®

Medical Ethics Department

Views and guidelines - free of charge from the Medical Ethics Department^
E-mail ETHICS@bma.org.uk

Website

http://www.bma.orq.uk/public/ethics/quide.htm\

+ 44 171 383 6286

Fax + 44 171 383 6233 i

O

Abortion, BMA Views on Law And Ethics (March 1997)

O

Advance Statements, BMA Views on (Revised May 1995)

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

Asylum Applicants - Medical Reports, Guidelines for Examining Doctors (January 1993)
Cardiopulmonary Resuscitation, Decisions Relating to (March 1993)
Circumcision of Male Infants: Guidance for Doctors (September 1996)
Confidentiality and People Under 16 (January 1994)
Doctor-patients: Treating, Ethical Responsibilities (March 1995)
Duty of Candour? Truth telling and rationing of resources (July 1997)
End of Life Decisions, BMA Views on (September 1996)
Female Genital Mutilation (December 1995)
Incentives to GPs for Referral Or Prescribing (Revised January 1997)
Intimate Body Searches, Doctors Asked to Perform (January 1994)
Paternity Testing (December 1996)
Persistent Vegetative State, Treatment of Patients in (Revised June 1996)
Police Surgeons, Revised Interim Guidelines on Confidentiality for (February 1998)
Prison, Guidance for Doctors Providing Medical Care and Treatment to Those Detained in (March 1996)
Release of Information About Deceased Patients, Requests for (Revised October 1993)
Release of Records to Solicitors for Litigation Purposes (Revised September 1991)
Shadowing (Work Experience) (June 1996)
Considering Surrogacy ? Your Questions Answered (February 1996)
Tracheal Intubation on Recently Deceased Patients for Teaching Purposes (September 1992)
Transplant of Tissues and Organs (Revised August 1990)
Trust in the Doctor/Patient Relationship - Guidance for Doctors and Patients on Professional Boundaries
(February 1997)

o

Xenotransplantation, the BMA's Views on the Ethics of (May 1996)

Discussion Paper - free of charge
O

Treatment of Patients in Persistent Vegetative State (PVS) (September 1992)

British Medical Association - CEHAT Conference - Bombay 1998

BMA

Medical Ethics Department
Books for purchase from the BMJ Bookshop
E-mail orders@bmjbookshop.com
®.. ..t.

Website http://www.bmipq.com/data/shop.htm

A?1

Fax + 44 171 383 6455

Advance Statements About Medical Treatment (1995)
ISBN 0 7279 0914 2
This code of practice for health professionals was prepared by a multi-professional group and reflects good
clinical practice in encouraging dialogue about individuals’ wishes concerning their future treatment. It has a
broad practical approach, considers a range of advance statements, advises of dangers and benefits of making
treatment decisions in advance and combines annotated code of practice with quick pull out guide for easy
reference.
Assessment of Mental Capacity (1995)

ISBN 0 7279 0913 4

Produced jointly by the BMA and the Law Society to give guidance to health and legal professionals, carers and
all those involved in looking after people with suspected mental impairment, it includes advice on the legal and
practical framework within which assessment of capacity takes place.
ISBN 0 7279 1006 X
Changing Conceptions of Motherhood (1996) - The Practice of Surrogacy in Britain
Developments in reproductive technology have opened up new opportunities for those unable to have children
in the usual way. But with these developments come new ethical and legal dilemmas. This book aims to equip
health professionals with the necessary information to help inform these decisions by bringing together
information on the medical, legal, ethical, psychological and practical aspects of surrogacy. It also aims to
inform the interested reader about the practice of surrogacy in Britain.
Human Genetics: Choice and Responsibility (1998)

ISBN 0 19 288055 1

This is an authoritative and up-to-date assessment of the ethical issues raised by human genetics. The BMA,
drawing on the expertise of a wide range of advisers, has produced a compact and accessible report on a subject
of increasing public concern. The report confronts the often conflicting demands of choice and responsibility,
opening up the debate about who will control the power unleashed by genetic research, and suggesting practical
solutions for doctors, counsellors, patients, and policy makers.

i.J

Medical Ethics Today: Its Practice and Philosophy (1993)
ISBN 0 7279 0817 0
By far the most ambitious overview published by the British Medical Association of the ethical questions which
most commonly arise in medical practice. The approach is patient-centred and the aim has been to produce a
working tool for doctors whilst recognising that debate of ethical issues extends far beyond the medical
profession.
Medicine Betrayed (1992)

ISBN 1 85649 104 8

This authoritative and informative report examines the responsibilities of doctors in the protection of human
rights. Its ethical guidelines will encourage doctors throughout the world to refuse to participate in any
procedures which would breach internationally accepted standards and help them make protests about such
breaches.
ISBN 0 7279 0912 6
The Older Person - Consent and Care (1995)
This working document is aimed at all those caring for older people. Prepared by specialists from the BMA,
Royal College of Nursing and Age Concern, it provides background information based on issues surrounding
caring for older people and practical guidance that can be referred to quickly on a daily basis. It includes case
studies to illustrate good practice; guidelines regarding consent and care; and general guidance about how to
address gaps between the theory and reality of care.

British Medical Association - CEHAT Conference - Bombay 1998

Medical Ethics and Human Rights:
Perspective, Approach and Work of the BMA
Ann Sommerville
This paper briefly covers:
1. the BMA’s interest in medical ethics and human rights;
2. how medical bodies generally can play a role in protecting human rights;
3.
how the BMA’s perspective and approach to human rights' issues have changed;
4.
some suggestions for future development.

Part 1 - The BMA’s interest in medical ethics
and human rights
For the past 150 years, the British Medical
Association (BMA) has been debating and writing
about issues of professional ethics. When it was
established in 1832, it listed among its main
objectives "the maintenance of honour and
respectability of medicine by defining those
elements which ought ever to characterise a
liberal profession". It saw medical ethics as
representing the collective conscience of the
profession and assumed that all doctors would
agree to bind themselves to a set of shared values.
When it actually came to trying to define those
values, the BMA noted that within virtually every
culture around the world, medical obligations
were expressed in similar terms. Compassion and
a duty to the needy continue to be recurrent
themes in most medical ethical codes. As the
Declaration of Kuwait states, doctors should focus
on the sick and vulnerable whether they be "near
or far, virtuous or sinner, friend or enemy" - thus
neatly encapsulating many of the themes medical neutrality in civil conflict, concern for
populations overseas and access to health care as
a human right - that are pre-eminent in the
BMA's current ethics work. From the outset,
other common concepts of medical ethics
included the duty to use medical skills wisely to
benefit patients, to influence society in a way that
promotes health and above all to avoid harm.
Over the years, BMA publications have reflected
a strong and persistent concern for the welfare of
vulnerable people. In the 1830s, when the BMA
was established, there were calls within the
medical profession for doctors to be the “natural
defenders of the poor and needy”. It must be
said, however, that often the best way to get
politicians interested was to appeal to their self
interest rather than their altruism or morality. In
British Medical Association - CEHAT Conference - Bombay 1998

1850, the BMA President argued that "neglect of
die poor was endangering the rich and that it was
better, because it was cheaper, to preserve the
poor man in health, than to maintain his widow
and orphaned children". As soon as it was
established, the BMA became involved in
campaigns designed to protect public health.
Later, the BMA’s concern turned to reducing
abuse within institutions of various types,
including prisons. A core principle echoed in
many BMA publications over the years is that the
practice of medicine is a privilege which carries
with it strong moral obligations. Just how those
professional obligations tie in with concepts of
human rights has become an increasing issue for
consideration.
In this century, with the growth of research by
human rights organisations like Anfnesty

International, it became evident that health
professionals are usually among the first peo pie in
society to witness the effects of violence and
human rights violations. Doctors are often the
only professional group to have access to a very
wide range of institutions - from orphanages to
prisons, police stations to mental hospitals,
rehabilitation centres to morgues - and may be in
a unique position to see the violence hidden from
wider society. Because they are among the first to
see evidence of abuse and because they have clear
ethical obligations, expressed in professional
codes, the BMA believes that doctors and their
professional organisations can - and should - be a
powerful influence in campaigns to reduce
violence.
What we have been increasingly
searching for, however, are very practical
measures that will help doctors do that.

The BMA’s strong interest in "human rights"
began twenty years ago when it received reports
about involvement of doctors in torture and
maltreatment of detainees in various countries.

In some cases, doctors not active in maltreatment
were said to have collaborated by producing false
medical reports and death certificates. The
opportunity for the medical profession to play a
key role in stopping torture was brought home to
British doctors in the late 1970s, when forensic
doctors in Northern Ireland tried to draw public
attention to evidence of ill-treatment of detainees
there. Eventually, the effort to document abuse
was successful and it was acknowledged that
doctors had contributed to the exposure of
maltreatment but it was also noted that some
doctors had become victimised themselves in one
way or another. Since then, the BMA has been
contacted by many doctors around the world who
take considerable risks to reveal instances of
abuse and maltreatment. A constant source of
profound frustration, however, has been our
inability to fulfill their expectations. Having
raised their hopes that the profession will
respond to their appeals, we still lack effective
response strategies or measures for ensuring their
safety and that of the victims they represent. Part
of our current work is to liaise with other medical
associations, organisations of lawyers and human
rights specialists as well as international
organisations to try to establish more reliable
monitoring of abuses and rapid response
mechanisms. Increasingly, we see the solution as
lying within strong networks of different
professionals committed to similar aims and
backed by influential voices - such as medical
associations - ready to speak out within the
international community.
Part 2 - Why and how medical bodies should
protect human rights

"The physician's role is always a political
one, whether physicians recognise it or not.
Even a decision to try to be 'apolitical' is a
political act; it permits others in society to
make the decisions that profoundly affect
the health of die society without
appropriate physician input. Since die
doctor cannot claim to be apolidcal, the
only question is what political role he or
she will play. Will it be centred around
short-run, self-serving demands or will it be
a role centred around die health needs of
people and efforts to move society and
medicine in directions that will meet those
needs? ” 1

2

First, medical associations must be convinced of
the relevance of human rights concerns to their
own work. This can happen either as human
rights being seen as part of medical ethics or as
part of a public health concern.
Medical
organisations should have an interest in all of the
factors which affect the health of a population.
Medical associations also have a duty to protect
the independence and safety of doctors. The
BMA regards these issues as "ethical" and as
"health policies" although some policies, such as
setting standards for HIV services or for how
doctors deal with evidence of violence against
women, could also be subsumed under a human
rights rubric. While preoccupied by such health
issues in the UK, the BMA has also increasingly
seen itself as having an ethical obligation to
campaign actively on policies which harm the
health of populations in other parts of the world.
At present, we are involved, for example, in
campaigns against the inclusion of medicine and
basic foodstuffs in trade embargoes against Cuba
and Iraq, campaigns against doctors participating
in judicial punishments and female genital
mutilation, campaigns against the manufacture
and use of land mines and the campaign to
reduce the Third World Debt which has a
disastrous health impact on poorer nations . In
the wake of the hurricane in Central America, for
example, the BMA issued a press statement
calling on the UK government to take the lead in
cancelling debt repayments from the countries
worst affected. Such activities are a central part of
the BMA's work and are seen as part of a medical
association’s obligations to promote public health
in the widest sense.
A key factor in developing human rights strategies
is the interest and political will of ordinary
doctors. Like many medical associations, the
BMA is a voluntary organisation representing the
interests of the doctors . Its policies and priorities
are determined each year by its members at an
annual meeting. Since the early 1970s, many of
the resolutions passed at these meetings indicate
a continuing preoccupation with issues of human
rights, social justice, the fate of patients and
colleagues in repressive regimes and the ability of
marginalised populations to a good quality of
health care. The BMA is committed to such
issues because it believes that they form natural
and correct areas of concern for the medical
profession. This view is reinforced by the letters
we receive from practising doctors. We see that
education in medical ethics and in concepts of
British Medical Association - CEHAT Conference - Bombay 1998

human rights are essential in helping to develop
awareness among doctors.

"Concern for human rights should be an
intrinsic part of the ethical responsibilities
of the medical profession. For doctors, an
individual's complete welfare is of
paramount importance. So many factors
contribute to a person's mental and
physical well-being. A doctor cannot work
effectively if social and political factors are
Where such factors are
ignored.
important, I believe a doctor has a duty to
speak out... I believe also that doctors
should actively campaign to expose and
eradicate human rights abuses and diat
abuse should be defined in the widest
sense. I would like to see the BMA take a
much more prominent role concerning
human rights abuses both here and abroad.
We must be seen to be confronting and
condemning abuses at home if we are
legitimately to criticise others elsewhere. As
a group, doctors have the potential to be a
very powerful influence but they will need
to present a united front."
Letter from a BMA member
Medical associations can contribute to training in
ethics and human rights in a variety of ways. The
BMA, for example, makes available ethical
guidelines and practical advice for people like
police surgeons on the Internet or by mail. It
runs an advisory help line for doctors faced with
difficult human rights dilemmas and this is used
by doctors in many parts of the world.
Unfortunately, there are seldom easy answers to
the questions they raise but we try to put them in
touch with others who may be able to help.
Education in medical ethics and human rights
can be conducted not just guidelines or through
discussion groups. We recently received, for
example, the Indian Medical Association's report
on Knowledge, Attitude and Practice of
Physicians in India concerning medical aspects of
Torture. The report was based on questionnaires
distributed by the IMA as part of an action plan to
mobilise Indian doctors on the issue of care and
treatment of torture victims. Over 70% of the
doctors who replied said that they had come
across cases of torture but only 18% knew where
to report it. We were very interested by the fact
that over 90% of the Indian doctors who replied
British Medical Association - CEHAT Conference - Bombay 1998

thought that there was a need to define further
medical ethics in India as part of the strategy to
reduce abuses. The IMA is planning to develop
continuing medical education programmes but
the effort of circulating the questionnaire widely
may itself be useful in raising awareness among
doctors.

Widespread surveys, such as the Indian one on
doctors' knowledge about and attitudes to tofture
have been carried out in several parts of the
world, including the Philippines. The BMA has
also circulated questionnaires in parts of Latin
America and Asia. Findings in the Philippines
indicated that many doctors were unsure about
what constitutes torture and showed "a significant
degree of tolerance for violent and coercive
behaviour against persons under detention".
This indicates that an important aspect of
training for prison doctors and police surgeons
concerns awareness of international legal
standards regarding treatment of detainees. Skill
in recognising and documenting the clinical
sequelae of maltreatment is also an obvious area
to be included in training packages supported by
medical organisations.
Professional bodies can also provide support to
rehabilitation
centres.
number
of
The
rehabilitation centres worldwide for torture
victims, staffed by paid and volunteer health
professionals has increased substantially. In 1993,
Amnesty International wrote to more than 100
groups reported to be working with victims of
organised violence in more than 25 countries. It
compiled a survey of the kinds of services on offer
and, by way of practical assistance, disseminated
information about how to apply for financial
support from the UN Voluntary Fund for Victims
of Torture. One of the consequences of the
expansion of these centres is that the ongoing
reality of torture is brought home to more, even
if still a small minority, of practising health
professionals and a specialised expertise in
physical and psychological rehabilitation is
rapidly developing in healdi care teams.
Medical associations can be influential because of
the power they are able to exercise over ordinary
members of the community. Another of the key
BMA principles is that those who are in positions
of power or influence have obligations to ensure
that such influence is used well to benefit people.
One way of doing this is by empowering patients
by giving them information about their rights and
3

about international legal instruments which
support diose rights. Another way is to try to
educate people about the pejorative effects of
cultural practices, such as female genital
mutilation or abortion of female fetuses.
Campaigns such as these are immensely sensitive
in that they involve concepts of cultural relativism
or cultural imperialism but nevertheless the
BMA’s line has been that doctors have duties to
try to explain to people why certain cultural
practices need to change.
Another highly
controversial campaign has concerned the
involvement of doctors injudicial punishments,
such as floggings, hanging or branding or
amputation. In its early publications, the BMA
shied away from addressing such issues which
were seen as cultural matters to be resolved within
each society. Increasingly, however, the BMA has
adopted the position that an ethical obligation of
all doctors is to try to reduce “harm” in its widest
sense within the population. This means that
doctors sometimes have to take an unpopular
position with regard to cultural or judicial
practices. The evidence that we have received in
compiling our latest human rights report is that
in many areas of Africa or Central Europe,
doctors pay a high price in terms of suffering or
assassination for trying to alter societal attitudes.

Medical associations can exercise political
influence for change within countries with poor
human rights records. They should also seek to
coordinate the professional response to violence
and abuse. Collaboration of doctors in human
rights violations continues to be documented in
countries like Turkey but it is too simplistic to
condemn those involved without acknowledging
the danger and threats which confront them.
What they really need are practical solutions
which allow them to fulfill their ethical
obligations without necessarily risking the lives of
themselves, their patients or their families. Thus
the BMA has become increasingly preoccupied
with the question of how human rights violations
can be documented by doctors in a way that does
not put either the victim or the doctor at risk but
allows
to
the
international community
understand and react to the reality of hidden
violence. We want safe reporting mechanisms
and easy access by doctors to information about
how to identify signs of abuse.
We have
supported, for example, a new UN post of
Rapporteur on the Integrity of the Medical
Profession, whose duties would parallel those of
the rapporteur on the independence of the
4

judiciary and who would monitor cases where
doctors were under threat to conceal evidence.
We are examining how abuses reported in one
country can be tried by courts in other
jurisdictions and the BMA has campaigned for
the establishment of the International Criminal
Court to deal with abuses of human rights. We
are working with networks of doctors who are
interested in sharing survival strategies and
campaigning on behalf of colleagues under
threat. We are examining international linkages
so that, for example, Turkish doctors can smuggle
out factual data about evidence of violence and
this can be interpreted by forensic specialists
outside die country. We are compiling a database
of the human rights activities of all medical
associations around the world By combining
different
elements
across
of expertise
international borders, we believe that ways can be
found of both exposing the violations while still
protecting the victims and dieir doctors.
In addition to major initiatives, medical bodies
can also carry out simply baseline activities. For
15 years, for example, the BMA has implemented
a letter writing campaign in response to evidence
of abuses of human rights anywhere in the world
which involved doctors either as victims or
collaborators.
Part 3 - How the BMA's perspective and
approach changed

In the past, BMA publications on human rights
concentrated
on
narrow,
traditional
a
interpretation of human rights. That is to say
they focussed primarily on the evidence of
medical involvement in torture or extra-judicial
executions. As we approach the 21st century,
however, the BMA has looked back at the wide
range of issues - social and cultural as well as civil
and political - that are encompassed within the
UN instruments. We are increasingly examining
how doctors can be effective in promoting civil
and political rights, such as a “right to health” as
well as in preventing abuse of the traditional
rights, such as freedom from torture and
maltreatment. Thus as it has become more
involved in human rights work, the BMA's
perspective has changed. In 1984, the BMA's
annual meeting called for a working party to be
set up to investigate allegations that doctors in
some countries were co-operating in state torture.
Two years later, the first BMA published a booklet
called The Torture Report. As its title suggests,
British Medical Association - CEHAT Conference - Bombay 1998

this brief report was concerned primarily in the
role of doctors as collaborators in the violation of
civil and political rights. It ignored matters such
as the growing role played by doctors in some
countries in carrying out or supervising judicial
punishments.

The BMA's 1986 Torture Report found
"incontrovertible evidence of doctors'
involvement in planning and assisting in
torture, not only under duress, but also
voluntarily as an exercise of the doctor's
free will". When the brief report was
received at the annual meeting of 1986,
members mandated the BMA whenever
possible to help and support doctors
anywhere in die world who are faced with
evidence of torture.
As medical and humanitarian groups gradually
learned of the BMA report and its promise to try
to provide help, a tide of appeals, evidence and
testimonies flowed in. Often frustrated and
desperate, doctors and medical students from
many different countries reported the familiar
indicators of routine or institutionalised abuse.
Disappearances of colleagues or patients,
unexplained deaths in custody, forensic evidence
of beating or torture, the presence of mutilated
corpses in police morgues, pressure on doctors to
sign death certificates without examining the
corpse, incommunicado detention and denial of
medical access to certain prisoners or police
refusal to allow a doctor to speak privately to
patients hospitalised in suspicious circumstances.
As an organisation without investigatory powers
or experience, the BMA was unable to provide
immediate and practical solutions. It could
document and redirect the evidence to other
agencies with more experience and influence.
Lobbying and letter writing campaigns on human
rights issues to heads of state, governments,
medical organisations or international funding
agencies, such as. the European Parliament, also
formed a continuing element of the BMA's work.
It was evident that more effective and less
piecemeal strategies were needed.
In 1989, another debate at the BMA's annual
meeting drew attention to this growing body of
material and asked for a new working party to
review it and produce recommendations for
action. This time a more substantial report,
British Medical Association - CEHAT Conference - Bombay 1998

Medicine Betrayed, resulted in 1992. Unlik^ the
earlier BMA document, it was not confined to
examining medical involvement in torture but
considered the role of doctors in a wide range of
human rights violations and in judicially
approved procedures such as execution and
corporal punishment. Balancing the picture, it
also drew attention to the way in which doctors
who attempt to resist collaboration in abuse
frequently fall victim themselves to harassment,
torture or murder. Forty-five recommendations
in the report set out a preliminary plan by which
it was hoped that medical associations and
individuals could begin to address abuses and,
hopefully, to construct a framework of protection
for victims. Education of the profession as to
a
their ethical
obligations
was
key
recommendation. Realistically, however, the BMA
was well aware that recommendations alone
would change nothing and that by far the harder
task lay in pressing for their implementation.
This is the focus of our current efforts in the third
book we are now preparing and for which
CEHAT is among the many expert bodies that has
provided advice. The BMA is anxious to move
away from just documenting bad practice to
providing concrete examples of good practice.
We notice that in many areas of the world,
lawyers’ organisations have been more successful
in protecting their own members and their
clients. Awareness of international law and
internationally endorsed standards of practice as
well as knowledge of how to use the UN
instruments has undoubtedly helped. We want
doctors to understand how this knowledge may
help to protect them and their vulnerable
patients. We understand that education is not
just something that happens in class rooms but
also by example and the proven experience of
others.
We have been collecting evidence by way of
interviews and questionnaires from doctors in a
wide range of countries. We are also visiting
detention centres and institutions in an effort to
identify good models of practice. The BMA is
also increasingly working on the issue of access to
health care and to a reasonable living
environment as a matter of human rights. The
longest chapter in our new book focuses on
"health as a human rights objective" and aims to
show how health professionals and human rights
workers often have shared concerns and common
We recognise that there is still
goals.
5

%

considerable debate about whether human rights
language should be extended to encompass issues
of poverty, justice, equity in regard to health.
Nevertheless, since we believe that well organised
networks of interest groups can exercise influence
over national and international policies on health
issues, we support the use of any terminology
which furthers that aim. One of our priorities is
to identify how organisations like ourselves can
work closely with other professionals and NGOs
who have similar aims.
Part 4 - Some
development

suggestions

for

future

Disseminating information and evidence about
abuse is clearly not enough. Practical measures
need to be found for moving the debate forward.
Issues that we consider in our new book include
ways in which alliances of disparate organisations
can be formed to pressure governments to act
and how regulations can be tightened to reduce
opportunities for abuse. Global communications
systems are facilitating the development of
international networks of health professionals,
lawyers, patient advocates and human rights
activists. More coordination is required, however,
to minimise the duplication of effort, especially of
evidence-gathering missions or trial observations.
As a contribution, the BMA like other
organisations, is compiling databases of material
about human rights.
A number of international health bodies, such as
the World Health Organisation (WHO) and
Commonwealdi Medical Association (CMA), have
made good use of the convergence of health and
human rights taxonomies by blending both
elements into their plans and educational efforts.
Some organisations, such as the BMA, are only
just beginning to explore these possibilities. The
late Dr Jonathan Mann saw this integration of the
different spheres of expertise concerned with
health and with rights issues as part of a “bridge
to die future”. He wrote that “lack of knowledge
about human rights among healdi professionals,
and about public healdi among human rights
professionals, is the dominant problem” for the
“nascent health and human rights movement”2.
He saw evidence, however, that this movement
was growing rapidly and its development would
inevitably accelerate once better methods of
cooperadon were established. We hope that the
development of such cooperadon through
regional, national and international networks will
6

i

be one of die key practical contributions of thi^
conference organised by CEHAT.
Strategies for cooperation on human rights issues
have been developing in a piecemeal fashion,
involving health professionals, lawyers and human
rights organisations. The IFHHRO network of
organisations at this conference among whom
CEHAT is a valued member, has been very
influential. It manages to work across national
and cultural boundaries. Good models like this
exist at national, regional and world level but it
seems they sometimes work on parallel, rather
than intersecting lines. Too often, it seems,
individuals and organisations with an interest in
these issues invest time and effort in reinventing
action programmes that have already been tried
out elsewhere. Where strategies have proved
successful in one context, information about
them needs to be shared with others facing
similar human rights challenges. Knowledge
about bad risks and failed missions also needs to
be shared in a manner which would help others
avoid the same mistakes.

We have spent a lot of time liaising with doctors
around the world in order to find examples of
good practice, workable models of what can be
achieved and measures which we hope will
protect doctors and vulnerable patients. Many of
the recommendationswe have made are already
part of the work of CEHAT and of the
Anusandhan Trust. That is to say that this
organisation and this conference provide good
models for other organisations and other
countries. The BMA is grateful to be invited to
this event in order to learn from - and hopefully
to pass on to others - the collective experience
and knowledge of those who are represented here
during this conference. We recognise, however,
that there are no easy answers to the dilemmas
which will be discussed here.

References
1.

Sidel V W, quoted in the new BMA book on
human rights and originally published in The
New Physician March 1986.

2.

Mann J, Gruskin S, The 2nd International
Conference on Health and Human Rights:
Bridge to the Future in Health Hum Rights,
special issue, 1997: 2 (3): 1-3.

British Medical Association - CEHAT Conference - Bombay 1998

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ETHICAL ISSUES FACING CURRENT MEDICAL PRACTICE
Ethics is derived from the word "ETHOS". Ethos is defined by
hich
Bernard Harding as comprising of distinctive attitudes w
A
characterise the cultural outlook of a professional group
1..J of customs" and commitment to a
"tradition"
or "sharing
particular system of values- which perhaps is the ambience or
the "environment" of the
-- institution.
ETHOS in a health care institution is dedication, A service to
humanity in pain or in sickness.
Medical Ethics is a set of moral codes
behaviour towards this task of health-care.

of

prof ess ional

Ethical code is set
set of guidelines formulated by members of the
profession with the help of lawyers/advocates, specialists in
health-care, religious leaders and members of the society.
The code helps to distinguish between right and wrong at a
equally
alternatives appear
given time
especially when
satisfactory. The code enables a correct decision and a
uniform decision within the group of professionals.
Is the above definition of Ethics acceptable in-toto ?
Situations where the "Code" is decisive
Ethic of confidentiality
Ethic of

informed consent"

Ethical rules governing biomedical research
Any other ?

5 'J

CLINICAL ETHICAL WORKUP
I

Medical facts : using the problem oriented medical workup

II

Human values and issues

III Practical general ethical fundamentals
IV

Identify the major conflicting values

V

Decision making

How does
medical ethics contribute to patient care?
Clinical ethics is intrinsic to the work of the physician and
the practice of medicine, The central focus of clinical ethics
ind ividual patient-physician decision making.
is individual
making.
Clinical
ethics seeks a right and good healing decision
decision for
for! the
particular patient.
Clinical ethics is often enmeshed in
factual uncertainty,
This is because it is often conducted in
an
emotionally
situation
charged
in
or
emergency
circumstances.
It is a fact that medicine and ethics are
inseparably 1 inked because the identification of conflicting
values, a inecessary step for ethics.
depends on the meidical
f acts.
context or facts.
In this short paper I will present! the
approach used in the clinical ethical work up of a patientl.
I . MEDICAL FACTS
Identify all significant medical factors and their
likely
consequences.
Without these facts a critical understanding of
how a case raises moral issues is impossible.
If the
prognosis is ambiguous because of improper/incomplete, medical
work-up moral issues arising may be impossible to resolve.
II. HLU.MA1L.. FACTO RS
These arise
in each case:
Patient's age,
attitudes,
occupation,
family situation, behavioral history indicating
attitudes and values,
religious beliefs and so on .
Human
factors often express values that come into conflict with
medical management and give rise to ethical dilemma.
The
family wants to know the prognosis of the patient, which the
physicians are uncertain of.

4

III

PRACTICAL GENERAL ETHICS FUHDAMENTAlJS

III. (i) Preservation of life.
Alleviation of suffering,
Injunction that physician
first do not harm"
(primum non
nocere).
Respect for autonomy:
Patient alone or their legal surrogates
have the right to control what happens to them.
Concept of social justice: An effort has to be made to ensure
that medical resources are allocated fairly.

r)

Beficience: act of benefiting patients.
Nonmaleficence: refrain from harm
Disclosure: Providing adequate and truthful information for
competent patients to make medical decisions.
Informed consent.
Brain Death and Organ Transplantation.
Withholding and withdrawing life support.
The vital concept of proportionate treatment: At leastc a
reasonable chance of providing benefits to the patient w hich
outweighs the burdens attendant to the treatment.
Benefits and Burdens: The reasonable possibility of return to
cognitive and sapient life as distinguished from biological
vegetative existence.e.g.
Instructions for “Code" versus “No
Code".
Effective communication with patients and
Some
f ami 1ies:
physicians communicate better than others.
Early determination and ongoing review of individual quality
of life values versus Quality of life years. The former is
essential in evaluating
the latter is
highly
patients,
controversial.
III (ii) Policy Guidelines in Hospital Departments
Criteria for admission to ICU.
Policy guidelines for ventilabory care.
Policy guidelines for dialysis
“No Code"
Assessment of Organ System Failure.
III (iii) Ethics in ICU
In the ICU ethical principles may be more difficult due to
environmental social and economic pressures.
Commonly used principles are Beneficence, Nonmaleficience and
Autonomy.
that may conflict:
Remember principles
eg.
values
the patients human
Autonomy.
Beneficence
If
Vs.
(interests and wishes), medical work up and ethical issues
were defined before admission to ICU by the patient their
of the (most
many
surrogates and the primary physician,
avoided.
could be
institutions
ICU institutions
ethically difficult
Primary care physicians are in a particularly good positioh to
inform the patient and family about the consequences of the
critical illness,
life support measures and to get their
response in order to help them to prepare durable powers of
attorney or living wills.

III (iv) Criteria for Advanced Life Support
Young patient

Previously healthy.

Strong constitution.

Disease potential self limited.

Criteria for

No Advanced Life Support
Long standing illness

Elderly
Terminal Disease

Emaciated chronically ill: eg. these do badly with ventilatory
care - "Can never be weaned off the ventilator".

IV. IDENTIFY
FOR VALUES:

THE MAJOR CONFLICTING

VALUES AND SET

PRIORITIES

V. DECISION MAKING
Standard academic tests can evaluate students and physicians
- ability to think clearly and critically about an ethical
Observation is the only way to evaluate Human values
d ilemma.
eg. whether the patient is treated with respect.
A clinical ethical work up provides the physician with a
mec|ical
for the best
and search
meaningful experience
knowledge available, address of, sensitive issues and how they
are dealt with by "problem solving skills".
Cases may be very simple or complicated.

A

ETHICAL ISUES IN CURRENT MEDICAL PRACTICE
Approaches to moral reasoning
Somen Das, Principal, Bishop ’s College, Calcutta and an ethicist writes the three discernible modes or
approaches to moral reasoning.
i)

The deontological mode : This lists duties to be observed and rules to be obeyed. This is based on the
past. People who in their wisdom have formulated guidelines that have stood the test of time and
serve well in the understanding of what is “right” and “wrong”. Examples of these documents are the
Manusmriti which provides a systematised scheme of codified conduct. The code of Hammurabi,
from ancient Babylon, the Hebrews had their “Torah” and the Muslims their “ Shariat

These religious dictates came to be interpreted in a legalistic, rigid and absolute ways.
It restricted freedom and creativity. Obedience to God replaced with rigid faithfulness to rules.
In the Bible Jesus leaches the rule of Love God and Love your neighbour . He removed all opposition
between law and love, and law and grace.
2) Situation or contextual ethics : This asks the question “what is happening ?” or “Who is affected”
rather than “ what does the rule say”? It is thus people oriented giving room to be subjective giving
consideration for the existing predicament or situation. There is a danger of being too subjective ending m
confusion because each individual’s subjectivity will be asserted and it may not lead to a practical action
plan for the situation.
3) Teleological ethics : This goal oriented. It looks to achieving the highest or the ultimate good.
The bible teaching is in this mode. The concept of God’s kingdom here on earth. The mandate for each
one of us to strive to spread the Gospel of salvation and life eternal.
The three modes of moral reasoning have their limitations , advantages and weaknesses. A certain
measure of integration is therefore required to achieve discernment and judgement.

Group discussion

Euthanasia
Mercy-killing bill of 1980 Vs The human rights bill

God has created us and given us life He is the author of life and He alone decides when a life will cease
The role of Advanced life- support in this context Who gets it ?
For how long ?
At what cost ?
Who decides ?

Premature babies and Life support for them What are the issues ?

How is a Health-care institution to handle these ethical issues ?

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JOURNAL OF THE CMF JANUARY 1997

7

Euthanasia: An Update
Andrew Fergusson

Introduction
Each of the seven editions of the CMF Journal
from January 1992 to July 1993 carried an article
on a different aspect of the euthanasia debate,
which was then raging nationally. These articles
were later lightly edited and bound together as a
CMF booklet,1 which came out in 1994.
j

This article is a brief overview of the world
scene, attempting to answer the question: \Vhat
has happened in the last three years?

I
'There should be no change in the
law to permit euthanasia'
were the first words in the press release1 from the
House of Lords Select Committee on Medical
Ethics, which accompanied their full RleportJ
published on February 17th 1994. | This
Committee had been set up after the Dr Cox and
Tony Bland cases, and it sat for a year taking
written and oral evidence. Christian Medical
Fellowship made a Submission,4 and individual
members of CMF gave oral evidence on behalf of
several different bodies.
The Committee was widely expected at first to
come down strongly in favour of legalising
voluntary euthanasia, then as 1993 went on there
was the expectation that a small majority might
conclude against legalisation, but then in 1994
came their unanimous rejection of a change in the
law. Why was this?

It is worth quoting at length from the press
release 2 which effectively summarises thejr full
Report:
‘Contrary to many expectations, the 14
members of the committee have reached a
unanimous conclusion. They acknowledge that in
difficult individual cases euthanasia may be seen
ANDREW FERGUSSON
General Secretary, CMF.

by some to be appropriate, but argue that w'ider
social considerations make its practice
undesirable. “The issue of euthanasia is one in
which the interest of the individual cannot be
separated from the interest of society as a whole. ’’
The committee argue that individual cases are not
sufficient reason to weaken the prohibition on
intentional killing which protects us all.
They also conclude that if the law permit cd
euthanasia, elderly and vulnerable people would
feel “pressure, whether real or imagined ” to
request it, and that it would not be possible to set
secure limits on its practice. “It would be next to
impossible to ensure that all acts of euthamisia
were truly voluntary, and that any liberalisation
of the law was not abused.”
Although rejecting euthanasia as an option, the
committee do call for a number of other changes.
They recommend improved public support for
the hospice movement, more training in palliative
care, and more research into pain and symptom
control.’

Why then is there still so much
pressure?
Right in principle and right in recommendations
for practice, this Report received overwhelming
support in a high-quality debate in the House of
Lords on May 9th 1994, during which a long
extract from a CMF Journal article was read out,
and in a white paper response5 from the
government at about the same time.
So why wasn’t this wisdom the last word on
the matter? Why, less than three years later, is
there still so much pressure? The answers are
fourfold:
1. As far as the media are concerned, good r ews
is no news. There remains widespread
ignorance that this Committee ever sat and
that the whole examination ever took place!
2. Some patients are still having bad deaths.
There will always be pressure for euthanasia

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JOURNAL OF THE CMF JANUARY 1997

while patients have bad deaths.
3. Much of the UK remains unconverted. One of
the many achievements of the 1993 campaign
was the unanimity amongst the Christian
church,67 that euthanasia was wrong. Scripture
is clear,’ and Christians have realised how
both the earthly and eternal perspectives of
Christianity change the debate.
4. In addition, there have of course been devel
opments internationally and in the UK itself
which have put the pressure on. These will
now be reviewed.
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International Developments

Australia

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At one stage it looked as if several of the different
Australian States would legislate for euthanasia,
but in the end only the Northern Territory went
for it. Northern Territory has a land mass about
the same size as France and Germany combined,
but has a population of only 150,000. Many of
these are Aborigines. Chief Minister Marshall
Perron had seen a ministerial colleague die of
cancer in 1989 and then in 1994 watched his
mother suffer what was described 'as ‘an
agonising death’. Normally conservative in his
life and politics, he proposed a Bill for voluntary
euthanasia and this was voted into law (by 13-12
on the first and most crucial vote and then by 1510) on May 25th 1995.
i
An interesting alliance of the ‘three As’ - the
Australian Medical Association, the Anglican
church and the Aborigines - sought to block this
legally. At the time of writing, two challenges, in
Northern Territory’s High Court and in the
Federal Court in Canberra, still stand, and in
terms of legal process these have a significant
chance of succeeding. However, one challenge
failed, and the law technically came into force on
July 1st 1996.
Whether he jumped the gun or not. Dr Philip
Nilschke, a middle aged GP and euthanasia
enthusiast in Darwin moved the public perception
on dramatically when on September 22nd 1996 he
ended the life of 66-year-old former carpenter Bob
Dent, who had suffered with prostatic cancer since
1991. Some perceive Mr Dent as ending his own
life when he answered three questions on a laptop
computer supplied by Dr Nitschke, pressed the

space bar. and activated an IV inltision of three
drugs (thiopentone, pentobarbitone, and atracurium).’ The pro-euthanasia lobby welcome this
technology, claiming it keeps the patient in total
control, and although the Northern Territory
legislation is clearly called the ‘Rights of the
Terminally III Act’, it is being promoted as an
example of physician assisted suicide. The rele
vance of this apparently new concept in the whole
debate will become clearer later in this article.

USA
State-wide citizens’ referenda to allow' lethal
injection euthanasia had failed narrowly in
Washington in 1991 and in California in 1992, but
in November 1994 the state of Oregon passed
Measure 16 by 53-47%. This gives qualifying
patients (capable adults and residents of Oregon)
with six months or less to live the right to ask the
attending doctor for drugs to end their lives ‘with
dignity’.10 Again, ‘physician assisted suicide’ has
seemed more palatable.
Appeals started and this statute is currently
awaiting a final US Supreme Court ruling,
probably early this year. However, in a worrying
ruling in March 1996 affecting nine western
States, a US Federal Appeals Court judge
concluded that a dying patient has ‘a strong
liberty interest in choosing a dignified and
humane death rather than being reduced at the end
of his existence to a childlike state of helpless
ness, diapered, sedated, incompetent’."
T his verdict was echoed a few weeks later when
the Second Circuit Court of Appeals struck down a
New York State law that prohibited physicians
from helping their patients die.’2 Both these
decisions are to reviewed by the Supreme Court.
However, it is not necessarily the courts who
really rule. All this time, retired Michigan
pathologist Jack Kevorkian has been continuing
to end patients’ lives. By miil-Septcinber 1996 he
had notched tip TO killings.” and courts had so
frequently failed to convict him that it is currently
unlikely he will be prosecuted again. Law that is
not enforced is law that is not respected, and law
that is not respected has effectively been
overturned.
In what was in my view its most outrageous
leading article ever, the British Medical Journal

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JOURNAL OF THE CMF JANUARY 1997

described Jack Kevorkian as ‘a medical hero’.14
The subsequent correspondence was decisive
seven letters ‘against’ published, and ‘we
received 17 other letters about the editorial, all of
which expressed views similar to those published
here’.15 We may think that 24-0 isn’t a bad score,
but has that editorial done lasting damage around
the world?

9

Back in the UK
These events overseas have had considerable
media coverage in the UK. and have influenced
the perceptions of a media and a public who’ve
forgotten the conclusions of the extensive 199394 enquiry.

Possible euthanasia cases
There have been a number of high profile cases
that did or didn’t gel as far as the Courts:

The Netherlands
It was the visit to Holland of some members of the
House of Lords Select Committee that was the
single most significant factor influencing their
eventual unanimous rejection of euthanasia. The
Remmelink Report of 199116 had shown that of
128,786 deaths in the Netherlands in 1990, 1.8%
were due to ‘euthanasia’, 0.3% to ‘assisted
suicide’, and 0.8% to ‘life-terminating acts
without explicit and persistent request’.
In other words, euthanasia was performed on
more than 3,000 people in the Netherlands in
1990, and in more than 1,000 of those it was not
. voluntary. In its Submission to the Lords
Committee4 CMF did not ‘accept the morality of
those cases in which euthanasia was “voluntary’’,
but here is unequivocal evidence of the reality of
the “slippery slope’’ - where “voluntary”
euthanasia is tolerated, there is an inevitable
progression to euthanasia which is not voluntary’.
The slide down the slippery slope has
continued in Holland. In June 1994 the Dutch
Supreme Court convicted but declined to punish a
psychiatrist for assisting the suicide of a
physically healthy patient with ‘a depressive
disorder in the narrowest sense’.17 Where children
are concerned, ‘dissension exists regarding active
euthanasia in the newborn, both opinions being
respected’,'• and most recently we read that,
allegedly, ‘Dutch patients complain about poor
access to euthanasia’.19 This claim results from a
survey by the Dutch Voluntary Euthanasia
Society which ‘will counterbalance the national
review of euthanasia policy ordered by the
ministries of health and justice ...’
This review had not been published al the time
of writing this article, but the Dutch are known to
be stung by international medical criticism of
their euthanasia practice and their relative lack of
high-quality palliative care.

I

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Nothing more was heard after the September
1993 report’” of high levels of morphine being
found in the exhumed body of a 25-year-old who
had died of spinal cancer, and at about the s ame
time a teenager was cleared21 of aiding | and
abetting the suicide of a friend with multiple
sclerosis to whom he’d given paracetamol lai lets.
In a bizarre verdict in October 1994, the
coroner for Avon included the word ‘euthanasia’
in his verdict on the death of an 87-year-old
woman with some symptoms of Alzheir icr’s
disease who had suffocated herself with a plastic
bag,22 and in December 1994 the Crown
Prosecution Service decided not to prosecute a
man who killed his terminally ill wife by a
massive overdose of diamorphine from a syringe
driver.23 The CPS is claimed to have had sufficient
evidence to prosecute, but ‘apparently decided it
would not be in the public interest Io do so’.
On November 29lh 1995 the CPS announced it
was not going to prosecute a father who confessed
in a tabloid newspaper and then at Poole police
station to killing his seven-week-old terminally ill
daughter because he could not bear to see her in
such suffering.24 Police had been advised there
was insufficient evidence for a realistic pnjspcct
of conviction.
On March 27th 1996 a ‘dedicated home help’
walked free from Winchester Crown Court2 after
being ‘charged with attempted murder and admin
istering diamorphine to endanger the life of or
inflict grievous bodily harin’, concerning a client
of hers who died in Southampton General
Hospital in December 1994. The judge. Mr
Justice Ognall, who had presided over the Dr Cox
trial, stopped the case, ruling that her prosecution
was not in the public interest, and a QC addedd that
the case went ‘beyond the strictly legal into
greater emotive significance’.

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JOURNAL OF THE CMF JANUARY 1997
I

Derek Rowbottom26 admitted on national
television in April 1996 dial he had attempted to
kill his mother in hospital with a morphine
overdose, but after a.lengthy CPS investigation he
was not charged. ‘His lawyer said the CPS took
the view that there was no medical evidence that
what the man did contributed to his mother’s
death.’27 Widespread coverage of the Rowbottom
case led to the headline in The Independent
‘Dozens confess after son’s “mercy killing’’’.21
In the case most recent at the time of writing,
37-year-old Paul Brady pleaded guilty in Scptland
to culpable homicide, and was formally admo
nished but not given a custodial sentence. He
admitted killing his 40-year-old brother who had
Huntington’s disease by smothering him with a
pillow after an overdose of temazepam and
alcohol.2’

Other cases
There have .been two other high-profile'cases
involving children in Britain:
Two-year-old Thomas Creedon who had
suffered from severe brain damage since birth
died of natural causes on February 26th 1996, but
his parents had campaigned for his artificial tube
feeding to be stopped, and the issue had reached
court. This particularly difficult case had paused
considerable debate.**
I
Since July 1995 the parents of brain-dainaged
toddler lan Stewart have campaigned con
tinuously for his life to be ended by j lethal
injection.”
j
Motor neurone disease patient Annie Lindsell
has campaigned in Parliament and elsewhere for
her ‘right’ to eventual euthanasia,’2 and another
MND patient recently ‘won her case’ for
euthanasia 8-4 before a TV ‘jury’.”
Since the death in March 1993 of PVS patient
Tony Bland, after the Law Lords confirmed his
tube feeding could be stopped, there have been
about 10 similar deaths, all following applications
to the courts. Law Commission proposals’4 which
included liberalising recommendations on this
matter, as well as potentially dangerous legisla
tion on advance directives and other controver
sies (amidst many good and necessary proposals
for the mentally incapacitated, it must be added)

were shelved" in lantiaiy BMfi. and al the lime of
wriling the proposed public consultation
programme has not begun.
As if all (his were not difficult enough to
follow, there have been other high profile cases
about withholding medical treatments''’’' which
some have confused with euthanasia.
The media appear to seek soundbites and
sensation, (he medical profession has a lot else on
its plate, the legal profession is moving in. and
the public is understandably confused. So what
happens next?

Physician Assisted Suicide
The Voluntary Euthanasia Society and the
Scottish equivalent the VESS are gelling better
organised. They know where (hey are going.
Both have draft Bills for physician assisted
suicide ready in case one of their (very few)
supporters in the House of.Commons gets a lucky
ticket in the Private Members’ Ballot.
They have chosen this approach as a soft way
in to euthanasia - it was physician assisted suicide
that was eventually successful with the voters of
Oregon, it is PAS that is (wrongly) perceived by
some as being the Northern Territory of
Australia’s approach, it is PAS which is popular •
with
euthanasiast
diehards
because
it
(apparently) leaves them with the final control,
and naive doctors may leel PAS is morally or
practically different from euthanasia.
Few who have really considered the ethics can
sec any significant moral'distinction. and most of
the weighty practical objections remain. 'Fhe
House of Lords’ Committee was dismissive: ‘We
recommend no change in the law on assisted
suicide’.’" Should such a Bill make a Private
Member’s appearance in Parliament, it can
quickly be dismissed.
But do the VES/VESS expect to change the
law upfront? They are relying on superficial
public sympathy, questionable opinion polls, and
getting away with it in the courts. If health
professionals could perform euthanasia and be
acquitted in court, which was the process in the
Netherlands from the 1970s onwards, then they
would come back later to ‘clarify the law’.

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JOURNAL OF THE CMF JANUARY 1997

. VES General Secretary John Oliver: T doubt
that (he politicians will have the balls to change it
themselves . . . they are too frightened of broad
ethical debates and of the pro-life groups accusing
them of Nazi-style eugenics. Instead, change will
probably come in the form of judicial review, with
the law being reshaped in the courts - exactly as it
was in Holland, in fact.’"

11

Good medicine
Second, we must recognise that there are bad
deaths happening still, but that is bad medic inc.
and the answer to bad mediefne is not killing
people, it is good medicine. We must work to
improve professional standards.

Christian hope
So what do we do?
First, we remember that we have the arguments,
and that we hold the ground. Although reporters
new to the issue are invariably liberal and initially
pro-euthanasia, every new story gives« the
opportunity to point out that in the lifetime of this
Parliament, we have assessed the case' for
voluntary euthanasia more thoroughly than ever
before in human history, and have concluded
against it. The counter-arguments are watertight
and that summary from the House of Lords’ press
release at the beginning of this review really says
it all.

Third, we must seek the conversion to Christ of
our nation.

Conclusion
At a time when the national abortion debai C IS
beginning to move our way at last, the pressure
for euthanasia must still be taken very seriously.
We have the arguments, we of all people should
be able to inspire good medicine, and wc must
pray and work for the soul of the nation.

Resources
The counter-arguments
’tC J

|

1. The compassion case for euthanasia stands or
falls on the answer to the question: Do we
have to kill the patient in order to kill the
symptoms?
The
palliative
medicine
movement has shown that-we can get good'
symptom control, and that patients can cope
- with residual symptoms provided they can
find meaning and direction in the time that
remains to them.
2. Patient autonomy is important, but there is no
absolute autonomous right to euthanasia. The
Lords’ Report includes the words from
Romans 14:7 ‘For none of us lives to himself
alone and none of us dies to himself alone’.
3. The only logical argument for euthanasia is
the economic one, and at the moment a large
majority sees it instantly as immoral. At a time
when like all countries in the developed world
the UK has to make rationing decisions,
euthanasia on economic grounds is a potential
reality to be feared. Surely even those initially
most sincere and idealistic in their support for
voluntary euthanasia must recognise that?

1. Surely Euthanasia is OK . . . Sometimes? .. . I.\n 'l it? /\
leaflet prixluccd by HOPE. Healthcare Opposed to
l-ulhantisia. Available tor pArp only liom the < Mi.
Office.
2. Euthanasia: Doctor’s Duty? Patient’s Ri^hi? A 24 page
booklet produced by HOPE. Available from the CMF
Office. £2 plus p&p.
3. Euthanasia. An edited collection of articles ... A 64
page booklet published by CMF. Available from the
Office. £3 plus p&p.

References
1 Euthanasia. An edited collection of articles from the
Journal of the Christian Medical Fellowship. London.
1994.
2 Press release from the House of Lords. Thursday 17
February 1994.
’ House of Louis Session 1993-94. Rc|x>fl of Ihr Srlrcl
Committee on Medical Uhics. London: HMSO. 1794.
4 Submission from the Christian Medical Fellowship to
the Select Committee of the House of Lords on Mpdical
Ethics. London. 1993. Reproduced in full in (I).
' Government Response to the Report of the Select
Committee on Medical Ethics (Cm 2553). Lt ndon.
HMSO. 1994.
* The Church of England, the Roman Catholic Cl lurch,
and the Free Church Council made a joint Submisj ion to
the Select Committee.

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JOURNAL OF THE CMF JANUARY 1997

1 Tlx: Evangelical Alliance and the British Evangelical
Council made a joint Submission to the Select
Committee.
1 Saunders I’. Thou Shall Not Kill. Chaplcr 2 in (I).
’ Zinn C. Doctor aids first legal euthanasia act. HMJ. 313:
KI5. 5 October 1996.
10
Charatan F B. Oregon’s voters approve assisted suicide
measure. BMJ, 309: 1391. 26 November 1994.
" Macready N. Assisted suicide is legal, says US judge.
BMJ. 312: 655. 16 March 1996.
11 Krauthammer C. First and Last, Do No Hann. Time
magazine, p49. April 15 1996.
“ DycrC. l;<N>lnolc Io: Woman challenges euthanasia law.
BMJ, 313: 643. 14 September 1996.
'• Roberts J and Kjellstrand C. Jack Kevorkian: a medical
hero. BMJ. 312: 1434. 8 June 1996.
” Seven letters under the heading: Jack Kevorkian: a
medical hero? BMJ. 313: 227-8. 27 July 1996. '
i«
van der Maas P J ct al. Euthanasia and other medical
decisions concerning the end of life. The Lancet. 338:
(>69-74. September 14 1991.
17 Ogilvie A D and Potts S G. Assisted suicide for
depression: the slippery slope in action? BMJ. 309: 4923. 20-27 August 1994.
'• Vcrsluys Z and de Lccuw R. A Dutch report on the
ethics of neonatal care. Journal of medical ethics, 21:
14-16. 1995.
'• Sheldon T. Dutch patients complain about poor access to
euthanasia. BMJ. 313: 961. 19 October 1996. ;
Dyer C. Police investigate death after morphine. BMJ.
307: 756. 25 September 1993.
Gorman E. Teenager cleared of aiding suicide. The
Times, 23 September 1993.
n
Bulletin ofMedical Ethics, p4. November 1994. Quoting
The Independent of 7 November 1994.

Bulletin vf Medical Ethics. p4. November 1994. Quoting
The Observer of 4 December 1994.
w Interview on Radio Solent, 29 November PHIS and
Initit’r News. p5. January |99(».
” Mollatd A. Nmsc cleared of meicy killing. Ihiilv Mail.
pl-2. 2K March 1996.
!• Bunyan N. Son admits giving drug overdose to mother
in agony with cancer. The Daily Telegraph. p3. April 13
1996.
n Image News. p3. September 1996.
Boggan S. Dozens confess alter son’s ‘mercy killing’.
The Independent I April l<>96.
Cluislic II. Man walks lice in Scottish euthanasia case.
BMJ. 3J3: 961. 19 October 1996.
Toolis K. A death for Thomas. The Guardian Weekend.
pl8-23. February 3 1996.
Pierce A. Parents beg for child to die by lethal injection.
The Times. July 17 1995.
V
Dyer C. Woman challenges euthanasia law. BMJ. 313:
643. 14 September 1996.
” Nothing but the Truth. Transmitted on Channel 4 on
October 13th 1996.
M Law Commission. Law Com No 231. Menial
Incapacity. London: HMSO. 1995.
” BBC Television News. 17 January 1996:
* Dyer C. Judge rules in favour of ‘Un not resuscitate’.
BMJ. 312: 11 15. 4 May 1996.
Bale J. Mother wins right to stop son’s surgery. The
Times, p 1. October 25 1996.
w House of Lords Session 1993-94. Report of the Select
('ommitlceon Medical Ethics. Paragraphs 2(»2 and 295
** Oliver J. Quoted in GQ magazine. February 1995.

JOURNAL OF THE CMF JANUARY 1997

13

Principles: Biblical or Bolam?
Ruth Sei wood
On April 15th 1989, football fan Tony Bland
became a victim of the Hillsborough Stadium
disaster in Sheffield. Surviving his initial crush
injuries, he was left with a diagnosis of Persistent
Vegetative Stale (PVS). An application was made
through Airedale NHS Trust to the High Court for
permission to withdraw tube feeding and ‘let poor
Tony die’. The verdict was given in favour.
Following an Appeal, this was upheld by the
House of Lords on February 4th 1993.'
In reality, the Bland case was conducted in a
moral vacuum, where ethics gave way to
expediency. The judges’ ruling was based,
erroneously in my view, on the Bolam principle.2

The Bolam Case

Standards of Care
In medico-legal scenarios, a judgement has to be
made as to what constitutes an appropriate
standard of care. Three elements are involved:
1) Does the action accord with accepted
medical practice?
2) Has informed consent been obtained?
3) Is it in the patient’s best interests?
On closer inspection, many of these concepts
appear nebulous; and depend in a circular manner
on the Bolam principle.

i

It is long established that if a doctor administers
treatment considered acceptable at the time, by
one responsible body of medical opinion, the
doctor cannot be found negligent. This remains
valid even if there is another responsible body of
medical opinion which considers the treatment in
question was wrong. This can be traced back to
the Bolam judgement of 1957.
In the case of Bolam v Friern Hospital
Management Committee [1957]/ a patient to
whom ECT was administered, sustained fractures.
No relaxant drugs or manual restraints were used.
At the lime two bodies of medical opinion were co
existent within the profession; one in favour of the
use of relaxant drugs and one against. There were
also two opinions as to whether, in the absence of
relaxants, manual control should be applied. The
doctor was therefore absolved from negligence.
In the head-note to the case, it was staled:
The jury was directed (!) A doctor is not
negligent, if he is acting in accordance with a
practice accepted as proper by a responsible
body of medical men skilled in that particular
RUTH SELWOOD
Clinical Medical Student, Guy's and St Thomas’.

act, merely because there is a body of medical
opinion that takes the contrary view.'

Accepted practice
Bolam: the bottom line
The gold standard test for appropriate care is
accepted current practice, which has beco ne
synonymous with the Bolam principle. As stated. the Bolam ruling’ asserts that:
‘A doctor is not guilty of medical negligence if
he has acted in accordance with a practice
accepted as proper, by a responsible body of
medical men skilled in that particular act. ’
Essentially, a doctor must demonstrate acccp cd
proper practice; as defined by peer consensus. In
other words, medical opinion, and not informed
ethical discussion or the rule of law. holds sw iv.
Bolam represents the bottom line. The law sets the
standard at that adopted by the medical profession.
What would other doctors do in the same scenar o?
All clinical controversies proceeding to court ire
ultimately judged with reference to the Bolam
principle; whether this involves withdrawal of ti be
feeding in PVS (as in the Bland case), the appropri
ateness of an operation, or non-treatment of a
handicapped child. In the UK, the im|X)rtance of
such peer consensus has been recently emphasized
in a number of legal cases.

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JOURNAL OF THE CMF JANUARY 1997

Bolam and Bland
In the Bland case, a ies|>onsiblc body of medical
opinion apparently decreed that withdrawal of
tube feeding was acceptable. The judges referred
to a paper on the treatment of patients in
Persistent Vegetative State, produced by the
BMA Medical Ethics Committee.' The document
was a Discussion Paper only and did not represent
a unanimous view (‘The issue of witholding life
prolonging treatments, such as artificial feeding is
more complex and the MEC expressed divergent
opinions upon it’). However, its publication two
months before the High Court hearing lent it
considerable weight. Thus there was an element
of collusion between the medical and legal
bodies. The paper restated uncritically an earlier
assertion that:
‘feeding/gastrostomy tubes for nutrition and
hydration are medical treatments and are
warranted only when they make possible a
decent life in which the patient can reasonably
be thought to have a continued interest’.
Arguing that futile medical treatments can be
withdrawn, the BMA concluded ‘The Committee
docs not see such a decision as in breach of a duty of
care . No subsequent verdict seriously questioned
this assertion; and in applying the Bolam principle,
the legal experts bowed to the medical ‘majority’.

Body of opinion?

i

An action is deemed defensible if a ‘responsible
btxly of medical men skilled in that particular act’
would have acted similarly. Consensus opinion
has; a reassuring ring. Yet, what constitutes
a *‘responsible body of medical men’ is a
surprisingly tenuous concept.
Medical consensus amongst the expert body
admitted in the Bland ruling, was less unanimous
than al first appeared. In the case of Sidaway v
Belhlem Royal Hospital/ complex surgery was
performed to the cervical spine. The surgeon had
warned of the complication of disturbing nerve
roots, but not of potential damage to the spinal
cord. Although the procedure was non-negligent,
the patient was left paralysed. Was the operation
appropriate? The Bolam principle was applied to
clinical judgement in the case. Due to the *
procedure’s complexity, it was performed by only
12 surgeons in the country. Two out of 1 I were

willing to defend the case. Ilicsc two wcic
admitted in court as a lesponsiblc h<»dy ol
consensus medical opinion.

Informed consent
How informed?
Appropriate care requires informed consent or
refusal to be obtained. An adult of sound mind is
entitled to refuse treatment. This absolute has
been eroded only in the case of Caesarian section,
which has been lawfully carried out without
informed consent. Informed consent even applies
under the Mental Health Act. A schizophrenic
patient detained under a Mental Health Act
section order was recently permitted to refuse
amputation for his gangrenous leg.
What constitutes informed consent? I licre is
no actual law requiring informed consent to be
obtained in writing. Written consent forms arc
circumstantial proof that a procedure has been
voluntary, not that adequate explanation has been
given. They are evidence of a process, not the
process itself. Informed consent perhaps fulfills
the following criteria:
•
•
•

Did the patient understand the information?
Did the patient believe the information?
Was the patient able to weigh the pros and
cons and form a judgement?

But what information should actually be
imparted? Unlike in the United States, the
question of how much to tell a patient undergoing
a procedure is not legal doctrine. It depends on
factors such as:
•
•
•
•

the seriousness of the procedure
the likelihood and severity of complications
the ability of the patient to take the
information on board
the impact of the information on the patient’s
state of mind and health

In other words, we invoke clinical judgement to
deline an appropriate level of information - and
revisit the Bolam principle. Again, the law sets the
level at the standard adopted by the medical
profession. What information would other doctors
imparl in the same situation? For instance, patients
arc now informed of failure rates before undergoing
sterilization. This represents a radical shift in policy.
The shift has occurred due to a change in medical

f

JOURNAL OF THE CMF JANUARY 1997

opinion, not as a result of legal or ethical decision
making. A doctor who gives as much detail as a
recognised body of medical opinion considers
appropriate would not ■tee held liable.

Consent and consensus
When Myodil (the contrast dye lophendylale,
injected into the spinal cord for myelography) was
first used, its potential crippling effects were
already known. This information was withheld in
obtaining consent. However, medical consensus
argued that the impact of the information on the
patient would have been detrimental. The added
stress would have caused the patient to shake on
the table to an undesirable degree! Practitioners
taken to court were cleared of negligence according to the Bolam principle.
Again, we have alluded to the Sidaway case.4
The paralysed patient was warned of the compli
cations of disturbing a nerve root (a risk of abput
2%), but not of potential damage to the spinal
cord (a risk of under 1%). Was this consent truly
informed? The test of the surgeon’s clinical
judgement was the Bolam principle. Medical
consensus cleared him of negligence; he was
acting in accordance with recognised medical
practice.
j

Key lessons
Perhaps the key lesson for future house-officers is
to ensure full and careful documentation of
consent in the patient’s notes. It is worthwhile
asking a consultant which complications he or she
would like mentioned. Although written evidence
of consent is not lawfully required, it is viewed
favourably in court. Good medical practice is
always more than the legal minimum. Christians,
too, must surely show more consideration than the
minimum. As well as a legal safeguard, pre
operative consent is necessary to patient care. It
ensures the patient is properly prepared. In 1767,
before the use of anaesthesia, it was thought
‘reasonable that a patient be told what is
about to be done to. him, that he may take
courage and put himself in such a situation as
Iff enable him Io undergo lhe operalion
One of the reasons behind increased litigation
is that in an increasingly perfectionist and

15

consumer-oriented society, people are less
accepting of complications. Obtaining written
consent enables realistic expectations to be given; “
preparing the ground for a less than perfect result.
This is especially so in day-surgery. where
patients will not appreciate the seriousness of the
operation and the slowness of recovery.

Patient's best interests
Doctor-derived?
Closely tied to the concepts of proper practice and
informed consent, is the idea that appropriate care
must be in the patient’s best interests. Only in the
case of organ donation, covered by a special Act
of Parliament,6 may the interests of another Party
be brought to bear.
Again, this concept seems reassuring. What are
the patient’s best interests; and who detern ines
them? Not surprisingly, we return to our old
friend, the Bolam principle. The patient’s best
interests are defined by what other doctors would
do in the same situation. The argument is circular.
In the Bland case, one judge’s attempt to derive
the patient’s best interests followed extraord nary
lines. He argued that Tony, if revived and asked
whether he wished tube feeding to be withdIrawn
on his return to PVS, would unhesitatingly answer
‘yes’. A weight of responsible medical opinion
held the same view. The Bolam principle was
invoked - to ‘let poor 'I’ony die’.

Interests or expediency?
We are indeed at a watershed where, whether a
patient lives or dies, will depend not on the skill,
but on the expediency of their doctor. In a recent
case, a grossly handicapped child was cared for by
the local authority. An injunction was obtained
preventing resuscitation in the event of collapse.
The child’s mother was unhappy with the injunction.
She obtained the opinion of a second doctor - that
Ik * st
not to resuscitate was not in the child
interests. The treating doctor, meanwhile, was
firmly of the opinion that not to resuscitate vas in
the patient's best interests. The court supported the
liealing doctor, upholding his ilecision not to
resuscitate. The treating doctor was considered the
best judge of the patient’s best interests.

JOURNAL OF THE CMF JANUARY 1997

16

Conclusion
Moral vacuum
Increasingly, decisions regarding appropriate
standards of care are taking place in a moral
vacuum. Medical consensus - as defined by a
nebulous ‘responsible body of medical experts’ seems to hold the upper hand. Proper practice,
informed consent and the patient’s best interests are
all ultimately detennined by the Bolam principle.
What would other doctors do in the same situation?
The Bolam principle is essentially a circular and
self-fulfilling argument. As the medical profession
departs ever further from its Christian and
Hippocratic roots, there is a real danger that medical
consensus will manufacture its own ethics - and its
own proper practices. In the future, whether a
patient lives or dies may truly depend on the relative
ethical expediency of the treating doctor.

Case declarations: the danger
A recent survey in the RMA News Review demon
strated that 46% of doctors would support a
change in the law, allowing doctors to comply
with terminally ill patients’ requests ; for
euthanasia.7 The suggestion has already been
formulated by a psycho-geriatrician. Dr Helme,
writing in the June 1996 Journal of the Royal
Society ofMedicine* that those wishing to change
the euthanasia law should employ the Bolam
principle. Doctors could first utilise the courts to
request declarations - as in the Bland case - that
in the particular circumstances of an individual
case, euthanasia would not be unlawful. A patient
applying to the High Court for such a declaration
would have to argue the general point from the
Bolam principle. It would not be difficult to prove
that a substantial body of respectable medical
opinion believes euthanasia, or physician assisted
suicide, to be a proper medical practice in such
circumstances. Once the courts were asked for a
substantial number of declarations, Helme argues
that Parliament would be likely to legislate. Such
legislation might then implement Euthanasia
Tribunals, based on the model of Mental Health
Review Tribunals.

Bolam: the challenge
The Bolam principle originated retrospectively; to
absolve of negligence in litigation, where medical

experts differed regarding optimal details of a
treatment. The ruling is now being employed pro
actively. in the procurement of individual case
declarations, to justify ethical expediency. Bolam
presents us with a challenge. The law sets the
standard at that adopted by the medical
profession. I am not arguing for a greater role of
law; rather that we strive for medical standards ol
the highest order. Our standards must not conform
to those adopted by our peers; but reflect those
adopted by God. As a responsible body of
Christian doctors and students, we must
remember our ultimate responsibility to God. We
need, more than ever, to speak out strongly lor
practices approved by Him.
It is essential that we highlight the dangers of
indiscriminate use of the Bolam principle. If we
cannot beat Bolam, we must be ready to join in.
voicing a body of Christian medical opinion.
CMF was able to bring a weight of opinion to
bear in the House of Lords’ examination of mercy
killing. We should not underestimate the impact
of Christian medical consensus; neither can we
rest on our laurels. Whereof we can speak, thereof
we must not remain silent. As Jeremiah’ acknow
ledged, ‘the word of the Lord has brought me
insult and reproach all day long. But if I cay, “I
will not mention him or speak any more in his
name,” his word is in my heart like a fire, a fire
shut up in my bones. I am weary of holding it in;
indeed, I cannot.” Biblical principles, not the
Bolam principle, should be our professional
guide. Let us be among those who can say:
•This has been my practice: I obey your
precepts' (Ps 119:56).

References
' House of Lords Judgement Airedale NHS Trust v
Bland. 4 February 1993.
2 Bolam v Friern Hospital Management Committee
(1957) 2 All ER ll«; IWLR582.
’ Discussion Paper on Treatment of Patients in Persistent
Vegetative State. Medical Ethics Committee of the
BMA. September 1992 pl6.
4 Sidaway v Board of (iovernors of the Belhlem Royal
Hospital and the Matidsley 11VK5| AC X7I. I All ER M3.
5 Slater v Baker and Stapleton, 95 Eng Rep 860 (KB 1767).
‘ Human Organ Transplants Act 1989.
7 ‘Till death us do part ?’ BMA News Review. September
1996. p23-25.
• T Helme, JRSM (1996) 89. 320-3.
’ Jer20:8b-9.

u,-

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17

JOURNAL OF THE CMF JANUARY 1997

Caring for Life
The Christian Alternative to Abortion
Phil Clarke

________

I

<jn ui - the Cross of- Christ involves much more than being willing to take a
Carrying
'stand on moral issues. It requires costly obedience; using our time, skills and
money in searching for compassionate Christian alternatives where the world
offers diabolical quick-fix solutions. Nowhere is this more true than in the issue
of abortion. Over 90% of doctor and student members of CMF surveyed
recently felt that there should be tnore support for Christian/pro-life pregnancy
crisis counselling and support centres. Here Southampton GP, Phil Clarke,
describes his own personal journey and that of his church in providing a
Christian alternative to abortion.
Since the passing of the Abortion Act in 1967
abortion has become a very contentious issue. In
debate, views are often expressed as being ‘prochoice’ or ‘pro-life’. Even amongst Christians
there is a wide diversity of views with both camps
trying to support their arguments from a biblical
basis. Whilst my own views are firmly ‘pro-life’,
1 find these particular labellings most unhelpful. It
is of course important for us as Christians to
debate the issue. I have not always held the views
that I hold now and it has only been through open
discussion and debate that I have come to believe
that abortion is something that grieves God’s
heart.
I believe the danger for us all as Christians, is
that while we continue to debate the rights and
wrongs of abortion, there remain thousands of
women who are facing unexpected pregnancies,
or who have been hurt through abortion and for
whom we are providing no help or answers. 1 in
sure that for most of us, whatever our personal
views are on abortion, we would agree that the
termination of the life of the unborn child is
certainly less than God’s best. II this is the case,
how are we able to help those who are facing
unexpected pregnancies or have been through the
pain of abortion?
PHIL CLARKE
GP, Southampton.

Helping hurting people

Js pives
In the parable of the Good Samaritan, Jcsu|s gives
should
behave towards
us a picture of how we !----------------those whose lives have been set upon by the
‘thief (Satan in John 10:10). As we read the story
in Luke 10:25, a lawyer tried to justily I is own
righteous position by asking Jesus who his
neighbour was. Jesus did not reply to this put told
him a parable; and then returned the question to
him by asking which man showed himscli to be a
neighbour. We do not need to look tar in our
nation today to see the lives of millions of people
who are suffering pain and anguish, sometimes
through their own misdeeds, but often through the
misdeeds of others. We have a choice, we can
either pass by on the other side or we can stop
what we are doing and reach out in mercy to those
who are in need. The essence of the parable was
that Jesus was addressing the heart attitude of the
listeners, condemning the inactivity and heartless
ness of those who would ignore the plight of
hurting people.
Since the change in the abortion law there have
been over four million legal abortions in this
country. I do not believe that any woman goes
through with an abortion lightly, but for many the
experience is one that leaves deep scars. The pain
that many women suffer after abortion and the
anguish of an unexpected pregnancy are forms of
suffering that as Christians we cannot ignore. In

18

JOURNAL OF THE CMF JANUARY 1997

my 14 years of general practice I have come
across scores of women whose lives have been
broken by an abortion. One of the saddest cases 1
have seen was a young woman who came on to
my list having been under a gynaecologist for
several years because of infertility. She was
desperate to get pregnant, but everything she tried
seemed to fail. One evening in surgery she came
to see me to discuss the next step for her.
Although 1 did not know her past history I
suddenly had an overwhelming sense that the
problem was that she had previously had an
abortion. I tried Io raise the question with her
gently by asking her if she’d ever before been
pregnant. At that point she broke down in tears
and explained that she had once conceived
without difficulty, but then had had an abortion.
Tragically for this poor woman this may have
been the only baby that she will ever conceive.

Involving the local church

4

I

II we arc to say dial alxn tion is wrong, wlial arc wc
going to do about it? For me this challenge came
just over ten years ago. As one of the elders in the
Community Church, Southampton, a question was
posed by one of our congregation. What did the
elders think about abortion? Al that lime, although
we disagreed with abortion, we had not given it
much thought. 1 was asked to formulate our reply.
Having qualified at medical school in 1976,1 had
spent some time in anaesthetics after house-jobs
where I had been confronted with abortion head
on. On the gynaecology lists to which 1 had been
assigned there were often one or two abortions,
and the more 1 was involved in these cases the
more uncomfortable I became. As I sought the
Lord concerning this issue 1 began to Iqc I more
and more that abortion was something that grieved
his heart, such that by the time I came to do a
gynaecology attachment I had decided that I did
not wish to be involved in abortion procedures. A
search of the Scriptures revealed the preciousness
of life within the womb (Psalm 139:13-16) and
the impartation of spirit before birth (Jer FS;
Lk 1:39-45). As a church we were therefore able to
say that we were opposed to abortion. Around
about the same lime, the church hosted a weekend
of evangelism training, and three eminent men of
God were asked to speak on evangelism.
Amazingly all three brought aspects of the same
theme.

Starting a Crisis Pregnancy Centre
They introduced tons the concept of social action,
with the church being involved not only in
speaking out on issues that as Clu istians wc felt
. were wrong, but more than this, to be involved in
the lives of people who were hurting because of
the wrong-doing. This took us back to the issue of
abortion and again the question; ‘if abortion is
wrong what are we going to do about it?*
In 1984 I was able to travel to the United States
with my wife, to look at a Crisis Pregnancy Centre
run by a church in Phoenix Arizona. 'Hie rising
tide of abortion had come to the United States
rather later than Great Britain with the Roe vs
Wade ruling in 1973. However, the church in
America has responded rather more quickly to
this issue by establishing a network of Crisis
Pregnancy Centres offering help to women facing
unexpected pregnancies. Having seen what was
possible, we returned to this country with the
desire to establish a pregnancy counselling centre
in Southampton. We were very grateful to receive
help from (he Lite Organisation and horn a group
of Christians in Basingstoke who hud just become
involved in the Life Centre in that town. As we
began to sliare the vision of the work amongst
other churches in Southampton, wc were thrilled
to receive the support and backing of many other
Christians (one of my chief joys of being involved
in this work has been the involvement of at least
15 different churches in Southampton in
providing practical help and support whether in
prayer, money or personnel). As we began to meet
month by month to plan the establishing of a
centre in Southampton, we saw many miraculous
interventions by God to help us attain the goal.
One single offering at a church Bible Week raised
over £13,000 which gave us a deposit for a
building which we purchased in a Southampton
suburb. Previously the building had been used as
a tailor’s shop and was readily converted into a
Counselling Centre. Just over a year after
beginning our planning for the centre, the doors
were opened and we began seeing women in
January 1987.

Meeting practical needs
The Centre offers free pregnancy testing, free
counselling and practical support lor women
facing unexpected pregnancies and wc very soon

■ fI ■

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I

JOURNAL OF; THE CMF JANUARY 1997

began to see women remicsting post-abortion
counselling. Although we disagree with abortion,
we recognise that many women will still feel that
this is the best pathway for their lives and we do
not seek to sit in judgment on them, but are there
to help them in their distress even should they
choose to go ahead with abortion.
This can often be terribly hard, but when Jesus
was faced with a woman caught in adultery,
whilst he did not condone her actions, neither did
he condemn her. Obviously we hope that each
woman will choose the alternative to abortion,
through cither keeping her baby or allowing a
baby to come up for adoption. Sadly adoption is
extremely rare nowadays, and understandably this
is probably the hardest choice for any woman. We
find that many of the women who come to us, and
who are intent on having abortions, feel in their
heart of hearts that this is something which is
wrong, but they are feeling pressurised to go
down this pathway by boyfriends, husbands or
family. Being able to share their feelings in a
confidential atmosphere and receive practical help
and support in their pregnancy, many change their
minds and choose to keep the baby. Practically we
are able to offer an ongoing support service,
including befriending, advice on financial and
social provision, advice and practical help on
housing and the provision of free baby clothes and
baby equipment if women are in financial diffi
culties. At one stage in Southampton we ran two
homes for single women and their babies. These
were extremely successful and we had a
continuing stream of referrals both from social
services and from our own centre. The houses
were always full and provided a place of safety
and friendship for young women going through a
very difficult time. Although we have now closed
these homes, we are delighted that two other
groups in Southampton have developed to take on
this vital and rewarding work.

The birth of a national movement
Having started modestly in 1987, we now see
between 130 and 150 women every month and as
many as 20 in any one day. Post-abortion
counselling has become another very large
commitment for the centre with several women
coming every week for this. Many of our clients
are young teenage girls and we felt that it would

19

be far more beneficial to try and reach these
young women before they were in the position
even to get pregnant, rather than to face them in a
crisis situation, fherelore we have recently
established a Sex Education Programme in the
Southampton area and are going into several
schools on a regular basis with this wotk.
Modules include teaching on abortion, HIV and
AIDS and on relationships. The programme has
gone down so well that we are having to expand
the team rapidly in order to cope with demand.
The church members at the Life Centre in
Basingstoke also felt that they should become .in
independent Christian Pregnancy Counsel I i ig
Centre. We began to work together to encourage
churches throughout the country to take up this
rewarding work. Conferences were held in the
late 1980s and it soon became apparent that God’s
Spirit had already been working in the lives Of
people across the nation to encourage them to be
involved. There were already the seeds of new
centres and very quickly these seeds grew and
bore fruit and new centres were established. Out
of these groups. Christians Caring lor Life w as
established and three years ago this was
incorporated as a new department by the CARE
Organisation in London. Now known as CARE
for Life, or aim is to educate the church on he
issue of abortion and encourage Christians to be
involved in Pregnancy Counselling Centres, To
date we now have 100 centres affiliated to CARE
for Life in all parts of the United Kingdom and
there are now affiliated centres in Europe, Africa
and the old Eastern Bloc Countries.

Our personal response
Whatever our views on abortion God calls us to
reach out to those hurting and in distress. Through
Pregnancy Counselling Centres we have hpcn
able to provide practical help and support to
women who are in crisis. We know that there are
many hundreds perhaps thousands ol babies who
are alive today who would otherwise have been
just an abortion statistic. As a general practitioner
I see many women every year requesting a
termination of pregnancy thinking that this is the
only way ahead for them. In the midst of a busy
such
surgery there is often little
iiitie time
unie to give to
io such
deserving patients. It is so reassuring therefore to
have a Pregnancy Counselling Centre that I can

20

JOURNAL OF THE CMF JANUARY 1997

refer them to, where 1 know (hey will receive the
lime, the love and the compassion which they so
deeply need.
An unexpected pregnancy will always mean a
crisis. Pregnancy Counselling Centres present a
positive alternative to abortion and provide
Christians with an opportunity Io be involved
practically in helping these women. I believe that
if we are to turn back the tide of abortion we must

* , but
reasoned aignmcnts.
those
who
arc in
demonstrate Chk I’s love to I
distress.
not

only

present

If you would like mote inloimalion about
Pregnancy Counselling Centres and the work ol
CARI- for Life, please contact:
CI L, PO Box -'X9. Basingstoke. I«i24 9(,)b
(Tc I:()I256-X5() HI)

1

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■-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Ethics, Equity and the Need for
Global Dialogue

a

• John H. Bryant
• International Consultation on Inter-religious
Dialogue in Bioethics, October 5-8, 1999

!2t

• German Institute for Medical Mission
• Tubingen, Germany

»

• What is the context in which these issues
are to be considered?
• We know we are living in a troubled world
- Social, political and economic instabilities
- War, violence, cruelty
- Growing market - thriving but unequal
- The certainty of an uncertain future
- Ethics is often tossed aside in such troubled
settings

Ethics, Equity and Global
Dialogue

Ethics, Equity and Global
Dialogue

• We need to focus on some specific, real
world examples —
- ethics/equity questions
- analysis of underlying substantive issues
- movement to Dialogue -- Local to Global
• Explore possibilities of promoting Global
Dialogue in ways that might contribute
broadly to useful patterns of action in
coping with threats to human well-being

• Yet, we know that societies can rise in
response to the poor and the vulnerable
• There is a splendid aggregation of
organizations with vision, commitments
• But the causes of vulnerability are not easily
Seen, often hidden, covered over
• We are not seeking a single model -- rather
a broad dynamic process, interactive,
evolving

L Benchmarks of Fairness
for Health Care Reform

Focal Points for Reflection on
Ethics and Global Dialogue
• I. Benchmarks of fairness for health care
reform
• II. Ethical parameters of research involving
human subjects

Ethics, Equity and the Need for
Global Dialogue

• Norman Daniels, et al: Oxford Press, 1999
• A New Tool for Policy Analysis Hl'

• Fairness
- multi-dimensional concept, broader than equity
- includes equity in outcomes, in access to all
forms of care and in financing
- includes efficiency in management, allocation.
- includes accountability, public empowerment
- appropriate forms of palient/provider autonomy!

W'X/fZ'/b

Underlying Ethical Foundations

Benchmarks

• Justice and Health Care
- Disease and disability impair the range of
opportunities open to individuals
- A principle governing equality of opportunity
provides a basis for regulating a health care
system
- The same theory can be extended to look
upstream from the point of delivery of health
care to the social determinants of health

• A Necessary Tool for Health Care Reform
- health systems undergoing reform
- economic growth -> different socioeconomic
classes with different health care demands
- failures of reform to meet health needs of
populations
- reform measures usually debated without
evaluation of impact on fairness

It

m.

The Benchmarks 1996 — USA

The Benchmarks 1996 — USA
Ri

• 1. Universal access -- coverage and
participation

• 6. Value for money — clinical efficacy

• 2. Universal access — minimizing
nonfinancial barriers

X

• 7. Value for money - financial efficiency
• 8. Public Accountability
• 9. Comparability

• 3. Comprehensive and uniform benefits

• 10 Degree of consumer choice

• 4. Equitable financing — community-rated
contributions
• 5. Equitable financing -- by ability to pay

The Benchmarks 1996 — Scoring
Applied to Congressional
Proposals

Adapting the Benchmarks to
Developing Countries
• Mexico, Colombia, Thailand, Pakistan

Score

• Public Financing/Private Practice —
single payer approach

4.1

• Heavily Regulated Market approach

2.8
• Moderately Regulated Market approach 1.1
• Least Regulated Free Market approach 0.7

at.

• Workshops in those countries in 1998-99
- Intense discussions with nationals plus
colleagues from other participating countries
- Consideration of cultural, economic, political,
geographic, technical parameters of health care
- Looked for interactions of each benchmark
with local national realities
- Adapted benchmarks to fit

2

Examples of Adaptation
• Examined all ten of the original benchmarks
from perspective of local context
• Modified them to fit local national realities
and circumstances
• Kept an eye on commonalities among
developing countries
• This is a tool supporting deliberations, not
an algorithm promoting fixed solutions
• Here are the Adapted Benchmarks, then:
three examples of adaptation

The Adapted Benchmarks
OF

•i

■

Benchmark 1 — Intersectoral
Public Health

The Adapted Benchmarks

• Extent to which population subgroups
benefit in terms of changing exposure to
risk factors
• Explicit attention to information needed to
monitor health inequalities
• Encourage intersectoral cooperation on
reforms, which may vary from country to
country -- violence reduction? clean waler?
• Community participation crucial

• 6. Efficacy, efficiency, and quality of health
care*
• 7. Administrative efficiency
• 8. Democratic accountability and
empowerment*
• 9. Patient and provider autonomy

Benchmark 3 - Non-financial
Barriers to Access
• Much more important for developing
countries than original Benchmarks for US
• Pakistan illustrated gender barriers
- lack of female autonomy
- lack of female health workers in rural areas
• Pakistan — lack of detection and treatment
of hypertension and diabetes
- higher prevalence in women: lack of exercise

• 1. Intersectoral public health*
• 2. Financial barriers to equitable access
• 3. Nonfinancial barriers to access*
• 4. Comprehensiveness of benefits and
tiering
• 5. Equitable financing

in

Benchmark 6 - Efficacy,
Efficiency,Quality of Health Care

%

• Primary health care focus
• Implementation of evidence-based practice
- Information infrastructure and data base
- Population health needs and utilization rates
• Community participation in assessing
quality of care
• Professional training focused on fair design
of system

■Si

Benchmark 8 — Democratic
Accountability, Empowerment

Benchmarks — Overall
ar

• Central element of fairness
• Requires transparency’, fair appeals process,
measures to ensure compliance
• Requires strengthened civil society with
advocacy groups and public debate
• Includes emphasis on empowerment
• Thailand -- reluctance to confront authority
• Pakistan — fear of retaliation of feudal
authority

Benchmarks — Toward Global
Dialogue
• This approach to health care reform —
adapting benchmarks to national settings -appears to have potential for broad usage
across economic and cultural boundaries
• The next steps - from four countries to
wider international dialogue — hold promise
for determining the fit of the benchmarks*
concept to multiple social, economic and
political settings.

A-

II.Ethical Implications—Research
Involving Human Subjects

*

From Nuremberg to Helsinki
• Nuremberg drew international attention to
inhumane research involving human
subjects
• A series of actions has follow ed leading to
highly refined concepts and mechanisms for
protection of human subjects
• An important task - building capacities of
developing countries to cope with ethical
dimensions of research involving human
subjects

• Widespread agreement that fairness is
included the dimensions of the benchmarks
despite wide variations in cultural
backgrounds of the participants
• Priority or weighting might vary among
countries for given benchmarks, depending
on cultural beliefs, but these differences do
not appear to detract from commonality of
basic value judgements.

• Not a new problem, but one generating
widespread controversy
• We reflect on this subject, not for the
controversy but to examine some
implications for developing countries
• Let us pick up a few issues to highlight the
global context, then we will turn to
developing countries

<£

The Declaration of Helsinki
w

*

• The WMA Declaration of Helsinki has
played a key role in this process
• Originated in 1964, revised in 1975, 1983,
1989. 1999-2000 — revision in process
• Provides guidance to physicians in research
involving human subjects
• 4iIt is the mission of the physician to
safeguard the health of the people”

J<

4

The Declaration of Helsinki

The Declaration of HelsinkiI

• The Declaration binds the physician with
the words: ‘*The health of my patient will
be my first consideration.'’
• "interests of the subject must always prevail
over the interests of science and society”
• The Declaration emphasizes informed
consent of research subjects

■w

• The refusal of the patient to participate in a
study must never interfere with the
physician-patient relationship

• The physician should ... obtain the subject's
freely-given informed consent, preferably in
writing.

'Bl

A'

The controversy

The Declaration of Helsinki
- Example of provision that some feel now
calls for change:
— Ever)1 subject must be assured the best
proven diagnostic and therapeutic method
..vs..
— ..dhe best proven method that ivould otherwise
be available to him or her

• In any medical study, every patient —
including those of a control group, if any should be assured of the best proven
diagnostic and therapeutic method.

IW

■»

- This provision is currently the subject of
major controversy- with global dimensions

• The 076 regimen to prevent transmission of
HIV from mother to fetus/newbon
- standard treatment in developed countries too expensive for developing countries
• Trials with reduced dosage
- undertaken in selected developing countries.
• The key question -- the controls?
- the best proven method - die 076 regimen?
- placebo controls?

'r.

N.

• Strongly divided opinion

CIOMS Guidelines

CIOMS Guidelines

• CIOMS International Ethical Guidelines for
Research Involving Human Subjects
- 1982, 1993, and now undergoing further
revisions -- March 2000
- Emphasizes implementation of Helsinki, but
with broader perspectives

• Research in underdeveloped communities
- Individuals and families in such communities...
may be relatively incapable of informed
consent because they are illiterate, unfamiliar
with such concepts of medicine ... or living in a
community- in which such procedures are alien
to the ethos of the community-

• does not focus on physicians alone
• acknowledges cultural differences in applying
guidelines

%

- Coordinating revisions with W'MA - Helsinki

5

CIOMS Guidelines

Other Guidelines

- the investigator must ensure that the research is
responsive to the health needs and priorities of
the community in which it is to be carried out
- the sponsoring agency should ensure that... any
product developed will be made "reasonably
available” to the inhabitants of the host
community or country at the completion of
successful testing
- CIOMS guidelines are consistent with using
placebo control in the 076 reduced dosage trial

• WHO Guidelines for Good Clinical Practice
(GCP) 1985
- Notes Helsinki and CIOMS as preferred Guide Lines
- Provides guidance for operationalizing Helsinki and
CIOMS “
• ICH — International Conference on
Harmonization
It

- Helps to earn- guidelines to practical applications

Capacities for Ethical Review in
Developing Countries

• Helsinki, CIOMS, WHO-GPC, ICH-GPC
- each with its own complexities, strengths,
weaknesses; each with its own place
- each being considered for revision
- other guidelines are being developed, some
independently of existing guidelines
- is this adding to understanding of ethical
subtleties, or creating contusing complexity?
- what is the direction and mode of convergence?

• Seminar—Ethical Review, Clinical Research
in Asian Countries - Chiang Mai, Aug 99
- WHO-TDR, World Bank, UNDP
- some countries well advanced, coping with
complexities:
• of ethical review of clinical research
• of handling multiple sets of guidelines

• Are we waiting here for a Global Dialogue?

- other countries at the beginning, limited
capacities, little attention from policy makers
- Here were interactions among different cultures

Capacities for Ethical Review in
Developing Countries

CHANGING PARADIGMS OF
INTERACTIONS OF DEVELOPED DEVELOPING SOCIETIES

• These changes are not limited to ethical
review processes, but extend across many
areas of development.

it

- Separates out responsibilities of various parties
- Strong on guidance for Clinical Trials

Multiplicity of Guidelines

• As we worked together on the problems and
processes of ethical review it became
apparent that major changes are under way
in which countries and their organizations
are interacting among themselves and with
donors and other international partners

JC

■’a

• Major paradigm shifts in the ways countries and
their institutions relate to one another
• Past -- Developed -Developing
- Top-down, one way flow - dependency
• Now — Developed - Develop(ing)ed
- Top-down, Bottom-up, Interactive

*

%

— Interactions among develop(ing)ed

- Webs of Relationships

6

CHANGING PARADIGMS OF
INTERACTIONS OF DEVELOPEDDEVELOPING SOCIETIES
• Analogy — wheel w ith hub and spokes
- Hub — donor, or centralized authority
- Spokes — one on one relationships, often
dependency
- Nodes on wheel — countries with sub-elements
(IRBs?)
- Tendency to inhibit flexibility, initiative and
interactions among developing countries

S

*

CHANGING PARADIGMS EVOLVING ETHICAL REVIEW
SYSTEMS
• From countries wailing for Helsinki, C10MS,
WHO-GCP, ICH-GCP
• To interacting, revising those guidelines
• To interactions among countries and between
institutions within those countries
• To promoting initiatives independently but
respecting overall interdependency
• These processes allowing adaptation to different
cultural requirements

Examples — Movement Toward
Global Dialogue
• I. Benchmarks of Fairness for Health Care Reform
• II. Ethical Implications — Research Involving
Human Subjects
• Their adaptations to developing country settings
• With each — movement toward Global Dialogue
• With each — locating the ethical content within the
substance of important development process
• Not definitive answers, but facilitated process
• The future is open

CHANGING PARADIGMS OF
INTERACTIONS OF DEVELOPED DEVELOPING SOCIETIES
• Shift to webs of relationships among those
elements
- Countries continue to interact with donors but
in less dependent relationships
- Countries and their institutions interact with
one another directly
- Develop their own initiatives, promote
independent joint actions
- New information system facilitate, promote
these interactions

•H

J

CHANGING PARADIGMS EVOLVING ETHICAL REVIEW
SYSTEMS

3

n,

• With national and international systems in webs of
relationships
• Can share ideas and experiences directly
• Can identify trouble spots - in countries, in
methods, new ethical dilemmas
• Can identify important gains and promote their
dissemination
• Can generate global agenda strongly relevant to
local needs, in all localities

x

Finally -- the Larger Context
ai

w

• These are examples, not ends in themselves
• The ends have to do with humanity
• These examples can be steps toward enhancing the
well being of humanity
• In the words of Hans Kung in the Global Ethic for
the International Parliament of Religions

• Believe as you will, but look for,
and accept, the commonality that
defines our interdependence.

*

*

7

Benchmarks of Fairness for Health Care Reform
In Developing Countries
1. Intersectoral Public Health
Degree to which reform increases % of population receiving the following
Basic nutrition
Housing
Environmental factors
Education and health education
Public safety and violence reduction
Development of information infrastructure for
monitoring health status inequalities
Research into interventions most likely to reduce health status inequalities
Degree to which reform has actively engaged intersectoral efforts at local,
regional and national level to improve social determinants of health
Degree to which vulnerable groups have been involved in defining these efforts.

2. Financial Barriers to Equitable Access
A. Nonformal Sector Coverage
Uniform access to the most appropriate package of basic services
Portable coverage
B. Insurance for Formal Sector
Reduction of the following obstacles to enrolling people in the formal
sector
Corruption and enforcement
Worker resistance to enrollment
Small employer resistance
Family coverage for enrolled workers
Drug coverage

3. Nonfinancial Barriers to Access
Reduction in geographical maldistribution
Gender
Status in family regarding decision making
Mobility
Access to resources
Reproductive autonomy
Cultural
Language
Attitudes and practices relevant to health and disease
Uninformed reliance on untrained traditional practioners
Perception of public sector quality
Discrimination by race, religion, class, gender, disease, including stigmatization
of groups receiving public care.

4. Comprehensiveness of Benefits and Tiering

All effective and needed services deemed affordable, by all needed providers
Reform reduces tiering and achieves more uniform quality

5. Equitable Financing
Is financing by ability to pay?
If taxed based scheme
How progressive?
How much reliance on cash payments?
If premium based
Is it community' rated
Reliance on cash payments

6. Efficacy, Efficiency and Quality of Health Care
Primary health care focus
PHC training for community based focus
Population based
Community participation
Integration with rest of health system (referals)
Intersectoral integration (social and environmental determinants)
Incentives
Credentialing and enforcement
Appropriate allocation of resources to PHC
Interactive community participation, including vulnerable subgroups
Implementation of evidence based practice
Health policies
Public health and clinical prevention
Therapeutic interventions
Incentives for clinical guidelines
Evidence based evaluation of methods for managing
utilization of health services
Information infrastructure and data base
Evidence based research on clinical and public health measures
Health services research on patterns of care
Population health needs and utilization rates,
including variation studies (with demographic differentiation)
Community participation in assessing quality of care
Measures for accreditation of plans and hospitals
Professional training
Curriculum focused on fair designs of system
Continuing education

7. Administrative Efficiency
Minimize administrative overhead
Inappropriate technology acquisition
Excessive marketing costs
Efficient use of personnel
Appropriate economies of scale
Minimize transaction costs
Cost reducing purchasing
Reduce price variation
Large scale drug purchasing
Reliance on (quality) generics where possible
Minimize cost shifting
Cost shifting to patients; from PC to Tertiary care; between schemes
Minimize abuse and fraud
Shadow (paid non-shows) providers
Practitioner auto-referral
Drug sales at profit by rural doctor
Billing practices
Un-credentialed practitioners in rural and urban areas
Vehicles and other perks
Inappropriate promotion of drugs and other devices
Appropriation of public resources for private practice

8. Democratic Accountability and Empowerment
Explicit, public, detailed procedures for evaluating services with full public reports
Use reports; performance reports; compliance reports
Use of adequately qualified consultants
Explicit deliberative procedures for resource allocation with transparency and
rationales for decisions based on reasons all fair minded people can agree are
relevant
Global budgeting
Fair grievance procedures
Adequate privacy protection
Credentialing and accreditation
Measures for enforcement of compliance with rules and laws
Strengthening civil society
Enabling environment for Advocacy Groups
Stimulating public debate, including participation of vulnerable groups

9. Patient and Provider Autonomy
Degree of consumer choice
Of primary care and specialty care provider
Of alternative providers
Of procedures
Degree of practitioner autonomy

Figure 1
US Benchmarks of Fairness
Benchmark 1: Universal access — Coverage and Participation
Mandatory coverage and participation
Prompt phase-in
Full portability and continuity of coverage
Benchmark 2: Universal access—Minimizing Nonfinancial Barriers
Minimizing maldistributions of personnel, equipment, facilities
Reform of health professional education
Minimizing language, cultural, class barriers
Minimizing educational and informational barriers
Benchmark 3: Comprehensive and Uniform Benefits
Comprehensiveness: all effective and needed services deemed affordable, by all
effective and needed providers, no categorical exclusions of servicees, like
mental health or long term care.
Reduced tiering and uniform quality
Benefits not dependent on savings
Benchmark 4: Equitable Financing — Community-Rated Contributions
True community-rated premiums
Minimum descrimination via cash payments
Benchmark 5: Equitable Financing -- By Ability to Pay
All direct and indirect payments and out-of-pocket expenses scaled to househo d
budget and ability to pay
Benchmark 6: Value for Money — Clinical Efficacy
Emphasis on primary care
Emphasis on public health and prevention
Systematic assessment of outcomes
Minimizing overutilization and underutilization
Benchmark 7: Value for Money -- Financial Efficiency
Minimizing administrative overhead
Tough contractual bargaining
Minimize cost-shifting
Anti-fraud and abuse measures
Benchmark 8: Public Accountability
Explicit, public, and detailed procedures for evaluating services, with full public
reports
Explicit democratic procedures for resource allocation
Fair grievance procedures
Adequate privacy protection
Benchmark 9: Comparability
A health care budget, so it can be compared to other programs
Benchmark 10: Degree of Consumer Choice
Choice of primary-care provider
Choice of specialists
Choice of other health care providers
Choice of procedure

I
£

involved in
Considerations
ICMR
•• shall be known as the

of
This ’"Statement
Human
Subjects
Resarch
on
Biomedical
shall
of
consist
the
Code and c
Research using Human
_j General Principles on
Statement
of
(a)
Subjects in Biomedical Research
on Research using
statement of Specific Principles Of Biomedical Research
HuSan lubjeotsh(b)
in specific areas
/
:1j principles may be
_
\
and
Specific
of General
to time.
These Statements
and added from time
'-L.
substituted <-varied, amended,
BACKGROUND

; , there
(1939-45),
Second World War
subjects
r‘
human
In the aftermath of the
about the use of thestatement on the
was an
The first international was the Nuremb•erg
an intensified concern
for medical research,
research using human subjects
The
voluntariness.
ethics of medical i
and
consent
1
of
1947, which emphasised
aftermath of the trial in
Code of
the
exper iments
Nuremberg Code was evolved in of conducting conditions where
practitioners accused
medical
their
their consent and in
medical research without put to grave risks resulting in 1948,
faculties.
In
the human subjects were H
t to tltheir 1j the
deaths and permanent impairmen Rights
Universal^ Declaration of Human
rights
of the United «•«««> e:
to
1
about human beings being Covenant
on Civix and Polrtica.
on
C1V1
- to torture or to
1966, the International
In
be
°ne shall
^ireatment3
or
or punishment,
to
/jis
consent
to without x-—
for
the
council
efforts
by
the
World
^h*'
preliminary
Following
Medical Sciences (CIOMS)
I
international Organisations> of 1 the Declaration 'at Helsii^i*. in
down
iation formula
ime and wnioix
which laid
-Medical Association
reseaich
m
is revised from tim
nedical
1964 which was
•l
in
research
Lples
b^
biomedicai
on
using
human
res
s
general principle
t released a
prescriptions
Research
pecific
^edical
addition to sp
the Indian
Council iderations involved
involved in Research
February 1980,. the
— Ethical
Cons
those involve-! in
••Policy statement on
of
benefit
all
the World Heilth
on Human Subjects” for the
in
1982,
International
in India.
issued Proposed
clinical research
Human
Subjects.
CIOMS
Organisation (WHO) and the Research
involving
for
Guidelines
Guidelines for Biomedical issued^’H
1991
in
tnd
the CIOMS
studies”
Subsequently'
Epidemiclog
ica1
Biomedical
Research
Ethical Review of
for
1-Guidelines
Ethical
’•International
1

involving Human subjects” in 1993.
Over the years, various
bodies in national jurisdictions have also laid down general and
specific principles in respect,of medical research generally and
in specific areas of scientific research entailing the use of
human beings as a subject.
These ’national’ Codes (drawn from
the international codes and the universal principles underlying
them)
outline ’guidelines’ to be followed in their respective
jurisdictions.
GENERAL STATEMENT

Medical and related research using human beings as subjects
must necessarily ensure that -

(i)

11.
The PURPOSE, of such research is that it should be directed
towards the increase of knowledge about the human condition
in relation to its social and natural environment, mindful
that the human species is one of the many species in a
planet in which the well being of all species is under
threat — no less from the human species as any other; and
that such research is for the betterment of all, especially
the least advantaged.

(ii) Such research is CONDUCTED under conditions that no person
or persons become a mere means for the betterment of others
and that human beings who are subject to any medical
research or scientific experimentation are dealt with in a
manner conducive to and consistent with their dignity and
well being under conditions of professional competence,
fair treatment and transparency; and, after ensuring that
the subject is placed at no greater risk, other than such
risk commensurate with the well being of the subject in
question in the light of the object to the achieved.
(iii)Such research must be subjected to a regime of EVALUATION at
research design and
all stages of the proposal i.e.,
and use of the
results
experimentation, declaration of
such
shall bear
evaluation
results thereof; and, that each
by
the
means
which they
,
in mind the objects to be achieved
anticipated
and
benefits
are sought to be achieved, the
dangers, the potential uses and
abuses <of the experiment
and its results and, above all, the premium that civiliseo
society places on saving and ensuring the safety of each
human life as an end in itself.
STATEMENT OF GENERAL PRINCIPLES

Any research using the human beings as subjects of medical
or scientific research or experimentation shall bear in mind the
following principles I.

Principles of essentiality whereby, the research entailing
the use of human subjects is considered to be absolutely
essential after a due consideration of all alternatives;r in
area of
the light of the existing knowledge in the proposed <--2

I

research and after the proposed research has been duly
vetted and considered by an appropriate and responsible body
of persons who are external to the research and who, after
careful consideration, come to the conclusion that tie said
research is necessary for the advancement of knowledge and
for the benefit of all members of the human species and for
the ecological and environmental well being of the planet.

various
sral and
illy and
use of
iwn from
ierlying
spective
II.
subjects
iirected
mdition
mindful
is in a
s under
er; and
>ec lly
person
others
medical
th in a
ity and
•etence,
ng that
an such
ject in

Principles of voluntariness, informed consent and commiunity
agreement whereby, research subjects are fully apprised of
’ ‘ of~ such research on the
the research and the impact and risk
research subject and others; and, whereby the research
from
abstain from
further
subjects
to
retain the
right
abstain
_r
legal
or
participation in the research irrespective of any
such
into
by
other obligation that may have been entered
-id XX. ,
----J
human subjects or someone on their behalf,
subject to -only
advance
consideration
minimal restitutive obligations of any
received and outstanding.
Where any such research entails
treating any community or group of persons as a research
subject, these principles of voluntariness and informed
consent shall apply, mutatis mutandis, to the community as a
who is
individual member
the subject of
—
whole and to each
<
the research or experiment.
Where the human subject is incapable of giving consent
or
essential that
research
cr
that
considered essential
and
it
is
to
incompetent
experimentation be conducted on such a person
nformed
give consent, the principle of voluntariness and ini —
consent shall continue to apply and such consent and
on behalf of
voluntariness shall be obtained and exercised
<
such research subjects by someone who is empowered and under
a duty to act on their behalfThe principles of informed consent and voluntariness
are cardinal principles to be observed throughout the
and
aftermatn
research
and
experiment,
including
its
continually
applicative use so that research subjects are
kept informed of any and all developments in so far as they
However, without in any way
affect them and others.
However,
undermining the cardinal importance of obtaining informed
k , the
consent from any human subject involved in any research,
evidentiary
nature and form of the consent and the
requirements to prove that such consent was taken, shall
depend upon the degree and seriousness of the invasiveness
into the concerned human subject’s person and privacy,
health and life generally, and, the overall purpose and the
importance of the research.

TION at
gn and
of the
11 bear
ch they
its^^nd
eriment
vilised
>f each

medical
ind the

III. Principle of non-exploitation whereby, as a general rule,
research subjects are remunerated for their involvement in
the research or experiment; and, irrespective of the social
and economic condition or status, or literacy or educational
levels attained by the research subjects kept fully apprised
of all the dangers arising in and out of the research so
that they can appreciate all the physical risks as well as

tailing
olutely
/es; in
area of

3

■

I
I
I

•' » research whether to themselves or
moral implications of- the
others, including those yet to be born.

I- Pri:
res*
imp*
mad*
eac
con
the
of
inc
per
pur
res
res
ava
a dm

subjects should be selected so that the
Such human
anu
and benefits of the research are distributed
burdens
without arbitrariness, discrimination or caprice.
inbuilt mechanism for
Each research shall include an
either through
subjects
for the human
compensation
to cover
means
any other appropriateby providing for
insurance cover or
all foreseeable and unforseeable risks
including
remedial action and comprehensive• after-care,
experiment,
experiment,
or
in
treatment during and after• the research
of
the
of any effect that
—
respect
xperimentltion7
“eas^res"3--on&
the human
are
recompense and rehabilitati
that immediate
™respect of all affected, if and when necessary.
taken
the
arch
Principles of privacy and confidentiality
IV.
t
.
identity and records of the human
huina" subjects
^on/idential;
and, ril.Pri
dis
as possible
kept
^ntial;
as far
are as
far as
subjects,
or experiment; are
Po^b
human
Kidconf
its
that
no details about identity of 4a^e
are
result in
would result
in the
disclosure
their
y,
which would
of:
ident
ben
the disclosure
sound scientific reasons whi
disclosed, without sound
_jet
essential
writing of the
for the purposes of
par
interventions,without the specific
authorised1 on their
concerned, or someone authorisea
human subject
Pri
nau the said human
subject
ensuring that
1--behalf; and, after
hardship,
discrimination
of
be
any form c- does not suffer from
of
participated
having
ens
consequence
or stigmatisation as a
anc
experiment.
in the research or
res
minimisation whereby^, due
of
Principles
and
risk
precaution
app
v.
of the 1research and
care and caution is taken at all stages research
its
mar
idea,
experiment (from its inception as a
the research or
res
subsequent research design, the conductof ensure that the
res
experiment and its applicative use) to
the
put
are
to
it
research subject and those affected by
adverse effects
minimum risk, suffer from no irreversiblethe research or
Pri
benefit from and by
generally,
and,
fui
taken to ensure
experiment; and that requisite steps
the
research
to,
that both professional and ethical reviewsof
and
ftoul
are undertaken at appropriate stages so that further
directions
thi
specific guidelines are laid down, ®nd
7 research or
ric
given,
in respect of the conduct of the ass
experiment.
* , the research
professional competence whereby,
Principles
condnloeKat all times by competent and qualified persons
VI.
_ __
---------- €
is (--and who have I.
Pr.
impartiality
and
integrity
who act with total
the
ethical
pr<
of
,
and are mindful
been made aware of,
respect
such
of
obt
considerations to be borne in mind in
pn
research or experiment.

re:
di.

4

ex
fo
th
co
wh
th
al

or
le

ad

or
gh
er
or
ng
in
or
re
re
he
ch
d,
S,

re
be
.er
:he
jet

.on
led
iue
and
Its
or
she
she
sts
or
ire
rch
and
ons
or

rch
ons
ave
cal
uch

transparency whereoy,
accountability and transparency
whereby, the
honest,
I_
is
full
____
L
____
•
disclosure
after
a
impartial and transparent manner
made by those associated with the research or experiment
any
each aspect of their interest in the research, and
subj
whereby,
ect
to
and
conflict of interest that may exist;
,-the principles of privacy and confidentiality and the rights
of the researcher, full and complete records of the r£search
inclusive of data and notes are retained for such reasonable
period as may be prescribed or considered necessary for the
purposes of post-research monitoring evaluation of the
research, conduting further research (whether by the initial
researcher or otherwise) and in order to make such records
and
the
legal
by
appropriate
available
scrutiny
for
administrative authority, if necessary.
j

of
________ in a fair,
I- principles
will be conducted
<
research or experiment

...» maximisation
-1----of- the public interest and of
II.Principle wx
of the
distributive justice whereby, the research or experiment ana
its subsequent applicative use are conducted and used to
benefit all human kind and not just those who are! s
socialy
in
and,
better
but
least
advantaged;
off
also
the
particular, the research subject themselves.
<■ •

_

• V

-1— •

* ♦Vi a -w « V-\ nr

+•

z*

Principle of Institutional Arrangements whereby, there shall
be a duty on all persons connected with the research to
ensure that all the procedures required to be^ompiied^with
institutional arrangements required to be made m
and all 1__
and
its
or
the
research
subsequent
use
of
respect
are
made
a
bonafide
and
transparent
in
duly
application
manner; and to take all appropriate steps to ensure that
research reports, materials and data connected with the
research are duly preserved and archived.

„fteh

Principle of public domain whereby, the research and any
further research, experimentation or evaluation in response
to,and emanating from such research is brought into the
public domain so that its results are generally mad^ known
scientific and other publications subject to such
through
those
and
researcher
are available to the
as
rights
associated with the research under the law in force at that
time.
the
whereby,
totality
Principle
of
of
responsibility
due
for
the
and
professional
moral
responsibility,
or
guidelines
of
the
all
principles,
observance
the
prescriptions laid down generally or in respect of
research or experiment in question, devolves on all those
directly or indirectly connected with the research or
experiment —- including the researchers, those responsible
' ' « research,
to the funding of" the
for funding or contributing
<
institutions where the research is
the institution
institution or institutions
various
persons, groups or undertakings
conducted and the
who sponsor, use or derive benefit from the research, market
-the product (if any) or prescribe its use — so that, inter
research
experiment
duly
or
the
is
the effect of
5

monitored and constantly subjectj to review and remedial
research and experiment and its
action at all stages of the 1----future use.
' , there is a general and
XII. Principle of Compliance whereby,
associated or
positive duty on all persons conducting,
of a human
connected with any research entailing the use
spirit of
the
subject to ensure that both the letter and directions and
these guidelines, as well as any other norms, laid down or
guidelines which have been specifically
■ ' i for that area of
prescribed and which are applicable
scrupulously
observed and
research or experimentation, are s
duly complied with.

6

AGENDA ITEM NO. 2
REOPRT FROM EUROPE TO PHM
A main development has been that Patricia Morton has taken over the
PHM liaison , especially as far as the PHA2 is concerned. Pat is also very
busy with Global Health Watch and I am mainly concerned to support her
We are making slow progress but are having great difficulties.
The languages make it very difficult for easy communication and so do
the occupations and pre-occupations of many actors. We cannot only use
English and Spanish. We simply do not have resources in terms of people
and funds to do as much as the situation demands. This is a source of
great stress for us. With the newer countries there are 46 countries in
Europe which now has a population of 730 000 000. For this reason we
think that we need to build up different groups - right now concentrating
on Southern Europe. Even tho’ the needs are greater in Eastern Europe
we do not have the contacts, languages, funds, people to do much. The
effort with St Petersburg (this city area has a population of 6 million) was
really good and they were responsible for the Russian translation, but
follow up now requires resources that neither they nor we have..
European Social Forum. (October 2004)
This was the most important activity in which IPHC was involved.
With Pat and newer groups from Italy, Spain and France, we were able to
organise two workshops on health.
1. The Right to Health and the Commercialisation of Health Care
This was IPHC with PHM. In fact Pam personally paid the £250
registration fee. Presentations dealt with the irreplaceable role of Public
Health Service, PFI, and the privatisation of hospitals especially in
reference to the Hungarian referendum, the European treaty and its
*
relation to the Right to Health, GATS and WTO.
2. The right to access as an essential condition to the right to health.
This was organised by the European Network for the Right to Health
Presentations dealt with access, health and migrants and the global ‘brain
drain’.
Alexis Benos was the key liaison person as he is in both groups
A group of about 20 of us met the following day at Medact offices and
plannee for further developments.

(W/ * *

It is important that members of this group (who represent mainly trade
union organisations) are able to go to PHA2 and that the quotas allow us
to develop the movement in Europe. They come from Italy, France, Spain
- the working languages were Spanish, Italian, French and English.
(Andreas Wulf was there from Germany). By the end of the day we
produced a statement in 4 languages.
See Appendix 1.
One important activity was support for the Hungarian referendum.
This was against the privatisation of hospitals. The case was won but the
turnout was not sufficient for it to be binding on the Hungarian
government. With more resources we could gave given more support to
this very important campaign.
Politics of Health Group
This is a well established group who began as Physicians for Social
Responsibility many years ago.
As IPHC/PhSVl/Global Health Watch I went with Pat, 'Robin Stott and
Dave McCoy to their AGM. They were interested and have agreed to take
on an active role as PHM UK and UK global health watch.
Other activities
Pat went to Milan and met health activists people from Lombardy.
Pam is going to Bologna in May to talk on a Masters course on
public/international health. She will also support a meeting on PHM Italy
and discuss participation in pHA2..
Pat will go to Barcelona for a European Right to Health Group (Southern
Europe meeting)
There are two other Europe meetings which we might try to go to or at
least sent information to -Thessalonica and Istanbul.
Pat will present our ideas of participation in PHA2. Our basic idea is that
we should not try to sent representatives from the 46 countries in Europe
as there js no way of selecting/let alone electing someone truly
representative. Instead we should concentrate on sending more activists
from countries where they are likely to make some progress and then
subsequently see what can be learned for other countries..
Translations
I hope to be able to co-ordinate with Abraham but by email before the
Cuenca PHA2..

2

Appendix 1
Call to action to defend the right to health and fight the
privatisation of health services in Europe
London, 15 October, 2004
The participants of the health seminars at the European Social Forum in London
propose that the Assembly of Social Movements adopt, as a priority, a campaign for
the right to health and against privatisation of health services in Europe. The denial of
the right to health, which is an outcome of neo-liberal policies, has dramatic
consequences for people in Europe.
Neo-liberal health policy has transformed people ’s health into a profit-making
commodity. The attack on public health systems and the privatisation of health
services throughout Europe prevents many citizens accessing health care.
Privatised services are more expensive and less accessible. Furthermore,
independent research is obstructed by market philosophy as funding is dominated by
corporate interests.
The Treaty of the European Constitution excludes the right to health which exists in
many State constitutions. The participants declare their absolute opposition to this
Treaty. They consider it to be the product of collusion between banks and economic
power which does not take the people of Europe into account. This is why we urge
you to vote against the Treaty in State referendums. We also reject all similar
agreements especially the Bolkestein Directive which is worse than Global
Agreement on Trade in Services (GATS).

The networks that organised the health seminars were the People’s Health
Movement and the European Network for the Right to Health supported by the Global
Health Watch. These networks are fighting for the right to free access to public health
services without discrimination. They are also struggling against fortress Europe
which denies the rights of immigrants to access health care and their right to live in
dignity. The networks propose to build a specific space for health at the
Mediterranean Social Forum, 16-19 June 2005 which will address these issues.
In addition, we are working with Latin American, African and Asian networks to
prepare for the International Health Forum on the 23-25 January 2005 before the
World Social Forum in Porto Alegre. We shall also participate in the Second People’s
Health Assembly in Cuenca, Ecuador, July 2005.

We propose a campaign against the privatisation of health services. We will launch
the campaign by supporting the struggle of Hungarian citizens who have organised a
referendum against privatisation of hospitals.
We call on everyone present here at the Assembly of Social Movements to
participate actively in the proposed days of action against the privatisation of health
services in Europe:
3 December 2004 - Day against the privatisation of public health and in support of
the referendum in Hungary.

3

18 February 2005 - Day against the European Constitution and the Bolkestein
Directive to coincide with the referendum on the European Constitutional Treaty in
Spain.
10-16 April- the Global Week of Action on Trade.

To get involved sign up to the new yahoo group Righttohealth-europe-subscribe@yahoogroups.com

Appendix 2
Notes on Bolkestein Directive
To what extend is PHA involved in lobby against the Bolkestein
Directive? Are there openings for collaboration and exchange of
information on this issue?
Oui friends in the European Network for the Right to Health (southern European
unionists) are very keen on this issue. The PHA is not involved so much in lobbying
at the moment but it is something we should definitely be more active in. We hope
that PoGFI - Politics of Health Group (who are taking on the production of a UK
health Watch) will include the debate in the publication.
We would be very interested in working more on this topic, we just need someone
within the PHM-Europe to lead on it.
Wemos is participating (through the Dutch GATS-platform) in a new
Dutch platform against the Directive. Countries are urged to take health care out.

*

4

M p- q
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Thursday, February 26, 20G4 2:51 AM
[southasianmedicalethics] Poll results for southasianmedicaletnics

The following
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southasianmedicalethics poll is now closed.

Here are the

Private practice by Doctors oe
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Govt.Medical Colleges and Hospitals all
over India to facilitate academics and
research and also to serve the poor and
needy population better?
CHOTCF.S AND RF.SUT.TS
- no,let them do,they aro^undor paid, 0 votes, 0.00%
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their own Nursing Hottia , 7.
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2/26/04

Do European registration
authorities ascertain
whether clinical trials in
developing countries have
been conducted in an ethical
manner?
A study by the Wemos Foundation, Amsterdam

wemos

At!
June 2007

June 2007

M3.01

Do European registration authorities
ascertain whether clinical trials in
developing countries have been conducted
in an ethical manner?

Contents
i.

Background

2. The form of the study
3.

Main findings

i
i
2

3.1. The form and membership of local ethical review committees is subject to little
investigation by European registration authorities

2

3.2. Little attention to the trials’ relevance for the research population

2

3.3. Little concern for the protection of vulnerable study populations

2

3.4. Ethical shortcomings are not automatically grounds for rejection

3

3.5. Registration authorities’ procedures are insufficiently transparent

3

4.

Summary of main findings

3

5.

Wemos’ concerns and recommendations

4

wemos
Expert meeting on clinical trials in European Parliament
On Tuesday November 6, an expert meeting in the European Parliament
took place to discuss the risks of conducting clinical trials in developing
countries and the responsibilities of the European Medicines Agencies (invitees only).
Participants included members of the European Parliament and representatives of European
Medicines Agencies, the pharmaceutical industry, civil society organizations, and other officials and
experts.
The meeting was organized by Ms Dorette Corbey, Member of the European Parliament for the Dutch
Labour Party, and Ms Annelies den Boer, Project Coordinator Medicines of the Wemos Foundation.

Clinical trials are increasingly being carried out on people in low-income and developing countries, n
connection with the cost savings that this can bring. Although international guidelines do exist to
specify the conditions under which such clinical trials must be carried out, in many developing
countries these conditions cannot be met, for example because of poor health systems or a lack of
supervision. The rights of trial subjects are therefore being inadequately safeguarded.
The European Union, as a consumer of medicines that are being tested in developing countries, has a
responsibility towards these trial subjects. During the expert meeting, the responsibility of European
Medicines Agencies in granting market authorization for medicines tested in developing countries were

discussed.
November 9, 2007
Source: website Wemos, www.wemos.nl (English)

European Voice
www.europeanvoice.com
Volume 13 Number 40
31 October 2007

wemos

Time to stop using the world ’s poor as guinea pigs
On Tuesday (6 November), a court in Nigeria will resume hearing a criminal case against the
pharmaceutical giant Pfizer over allegedly illegal clinical trials. A total of €1.94 billion compensation is
being demanded and the prosecution of nine Pfizer doctors. Pfizer denies that the trial of its antibiotic
Trovan was unethical and says that it was at least as effective as the best available treatment.
In the European Parliament on the same day there will be an expert meeting to discuss the risks of
conducting clinical trials in developing countries and the responsibilities of the European Medicines
Agency (EMEA) and the national medicines agencies in each member state.
Whatever the outcome of the Pfizer case, it is clear that new medicines are increasingly being tested
in developing countries, allowing pharmaceutical companies to reduce costs and, in the absence of
strict regulations, to complete their trials more quickly. An estimated 40% of clinical trials now take
place in Asia, eastern Europe and central and south America.
There is persuasive evidence that not all are conducted in an ethical manner. In 2006, the Wemos
Foundation and the Centre for Research on Multinational Corporations prepared an overview of 22
known examples of unethical clinical trials. A particular worry is that, despite the rules, medicines
which have been tested in an unethical way reach the European market.
Primary responsibility for assessing whether research proposals meet the ethical requirements lies
with the ethical review committees in the developing countries where the tests take place. The find ngs
of the Indian Council of Medical Research were that such committees are as a rule inadequately
equipped to fulfil this task, and the safety and rights of trial subjects are put at risk.
The EMEA and national medicines agencies that are responsible for issuing the market authorisation
for any new medicine could exert a vital control function. Yet despite the directives on this topic, they
devote little attention to ethical aspects of clinical trials.
An exploitative relationship to the developing world could in reality be avoided quite simply. All clinical
trials outside the EU should be stringently reviewed and marketing authorisation withheld wherever a
drug has been tested in a less than fully ethical manner.
It is time to stop using the world ’s poor as our guinea pigs.
Annelies den Boer
Wemos Foundation
Amsterdam
Copyright 2007 The Economist Newspaper Limited. All rights reserved.

M3.01

Do European registration authorities
ascertain whether clinical trials in
developing countries have been conducted
in an ethical manner?

June 2007

1. Background
Medicines are increasingly being tested in low-income and developing countries. This
allows pharmaceutical companies to reduce costs and to complete the clinical trials more
quickly than would be possible in the West.
In order to receive a marketing authorization, whereupon they can be sold and used within
the European Union, medicines must have been tested in an ethical manner. Commission
Directive 2003/63/EC states: “To be taken into account during the assessment of an
application, clinical trials, conducted outside the European Community, which relate to
medicinal products intended to be used in the European Community, shall be designed,
implemented and reported on what good clinical practice and ethical principles are
concerned, on the basis of principles, which are equivalent to the provisions of Directive
2001/20/EC. They shall be carried out in accordance with the ethical principles that are
reflected, for example, in the Declaration of Helsinki.”
Primary responsibility for assessing whether proposals for clinical trials meet the ethical
requirements rests with the relevant ethical review committees in the low-income and
developing countries themselves. Nevertheless, research done by, amongst others, the
Indian Council of Medical Research reveals that these committees are often inadequately
equipped to fulfil this task, whereupon the rights of the trial subjects may be undermined
and their safety put at risk. This serves to emphasize the importance of the control function
of the European registration authorities which are responsible for issuing the marketing
authorization for any new medicine. The Wemos Foundation has therefore conducted a
study to examine the degree to which European registration authorities ascertain whether
the clinical trials for new medicines have been conducted in accordance with the ethical
guidelines.

2. The form of the study
Do European registration authorities ascertain whether clinical trials in developing countries
have been conducted in an ethical manner? If so, how? In late 2006, Wemos submitted
these questions to all 25 European registration authorities, and to the coordinating body, the
European Medicines Agency (EMEA).
Ten registration authorities responded by telephone, and answered a comprehensive
questionnaire which examined the various criteria set out in the Declaration of Helsinki (see
Box 1, below). Two authorities returned a completed questionnaire by e-mail. Thirteen failed
to respond at all, despite repeated attempts to contact them. One agency declined to take
part in the study. The twelve registration authorities which did take part represent both the
established and the new European Union member states.
Wemos collated the information gathered during the study to form a report in which the
authorities’ responses are presented anonymously. Copies of the report may be obtained
from the Wemos office. Here, we present the main findings of the study, followed by a
number of conclusions and recommendations. The word ‘respondent ’ refers to a European
registration authority.

1

M3.01

Do European registration authorities
ascertain whether clinical trials in
developing countries have been conducted
in an ethical manner?

June 2007

3. Main findings
3.1. The form and membership of local ethical
review committees is subject to little
investigation by European registration
authorities
Most respondents claim to ascertain whether the relevant clinical trials have been approved
by a local ethical review committee. However, only two state that they also ascertain
whether the form and membership of this committee meet the requirements set out in the
guidelines for good clinical practice. According to these guidelines, the committee must be
independent, which entails that no member can have any affiliation with the parties who
finance or carry out the clinical trials themselves.

3.2. Little attention to the trials' relevance for the
research population
Two of the twelve respondents state that they ‘sometimes examine dossiers from
developing countries more critically [than others]’. Only two respondents state that they
devote specific attention to the question of whether the clinical trials concerned are of direct
benefit to the research population. The Declaration of Helsinki expressly states that
research of this nature can only be justified if the results are likely to benefit the research
population. This would be the case if, for example, the drug being trialled is intended to
treat or prevent a condition which is particularly prevalent in the country concerned. In this
context, one respondent stated, “the developing countries are used to test drugs for the
developed countries.”

3.3. Little concern for the protection of vulnerable
study populations
According to the Declaration of Helsinki, vulnerable research populations must be afforded
special protection. However, only two of the respondents examine whether the clinical trials
have involved (groups of) vulnerable test subjects. None of the respondents consider
whether subjects have access to the best available medical treatment after the trial, which is
another requirement stated by the Declaration. Respondents regard this as the
responsibility of the pharmaceutical companies and the governments of the developing
countries.
Four respondents attempt to ascertain whether the research subjects have been adequately
informed about the form of the trial and the possible risks. They do so by a variety of
means, including checking that the registration dossier contains full patient information.
Only one respondent ascertains whether the subjects have indeed read and understood the
information provided, and whether they have given free and informed consent. Another

2

M3.01

Do European registration authorities
ascertain whether clinical trials in
developing countries have been conducted
in an ethical manner?

June 2007

respondent states that these aspects are checked during an inspection on location.
However, such inspections are themselves infrequent.
When assessing the registration dossier, none of the respondents examines whether the
test subjects have been paid to take part in the clinical trials.
Respondents consider that responsibility for ensuring compliance with the ethical guidelines
covering the above points falls to the local ethical review committees.

3.4. Ethical shortcomings are not automatically
grounds for rejection
The respondents state that, even where clinical trials have been conducted in a developing
country in a manner which may be considered unethical, this is not an automatic reason for
refusing the European marketing authorization. Only one respondent states that ethical
shortcomings are likely to lead to postponement or withdrawal of the product approval.
Another respondent states that the registration procedure would be influenced, but does
not give further details.
It is common for a medicine to be tested in several countries simultaneously. “Even if the
trials supporting one application were not entirely in keeping with the requirements, the
others may be,” states one respondent. “If the other trials confirm the efficacy and safety of
the product, we can then issue the marketing authorization, ” confirms another, “but we
cannot penalize the applicant.”

3.5. Registration authorities' procedures are
insufficiently transparent
Only seven of the twelve registration authorities make information concerning the
assessment procedure for a new drug publicly available, either on its own website, the
website of the EMEA, or on request. This means that information concerning the ethical
aspects of the clinical trials’ assessment is not widely available.

4. Summary of main findings
• The European registration authorities do very little to ascertain whether clinical trials in
developing countries have been conducted in an ethical manner.
• Even if a medicine has been subject to unethical testing, this will not necessarily preclude
its approval for sale and use in Europe.
• The European registration authorities place much of the responsibility for ensuring
compliance with the ethical guidelines at the door of the ethical review committees in the
countries in which the clinical trials take place. However, they do little to check whether
these committees meet the guidelines for good clinical practice in terms of form,
membership and performance.
• Many European registration authorities do not publish information concerning their
assessment of the registration dossier.

3

M3.01

Do European registration authorities
ascertain whether clinical trials in
developing countries have been conducted
in an ethical manner?

June 2007

5. Wemos' concerns and
recommendations
It is a cause for concern that, despite the existence of European Directives on this topic, the
registration authorities devote so little attention to the ethical aspects of clinical trials, as set
out in the Declaration of Helsinki and other documents. It is notable that these authorities
often abdicate their responsibility for the ethical aspects to the local ethical review
committees, even though it is known that these committees frequently fail to observe the
extant rules and do not have adequate capacity.
The European registration authorities’ shortcomings with regard to control have far-reaching
consequences, not least in terms of the vulnerable position of the trial subjects. It is highly
questionable whether the trial subjects in low-income and developing countries have indeed
given full and informed consent. After all, many are illiterate, while the relationship between
doctor and patient is hierarchical. Trial subjects will blindly follow the advice of their doctor,
while that doctor may have a vested financial interest in recruiting as many trial subjects as
possible. By virtue of their poor economic position and the lack of proper supervision and
regulation, trial subjects in the developing countries are clearly more vulnerable than their
counterparts in the West. Participation in a clinical trial may represent their only hope of
medical treatment. After the trial is completed, they will not have access to an adequate,
well functioning health system in which there is an adequate supply of drugs. It is therefore
essential that effective agreements are made with regard to subjects’ access to care after
the trial has been completed.
The fact that the registration authorities devote so little attention to whether the trial is
relevant and of benefit to the research population exacerbates the risk that trial subjects will
be misused, for example to test drugs which will benefit primarily the West. This type of
exploitative relationship can be avoided, at least in part, by subjecting all clinical trials
conducted in developing countries to stringent review, and by withholding marketing
authorization for any product which has been tested in a less than fully ethical manner.
Wemos believes that the situation in the developing countries demands greater care and
responsibility on the part of the European registration authorities. It is wholly unacceptable
for drugs which have been subject to unethical testing to be approved and admitted to the
European market.

4

Do European registration authorities
ascertain whether clinical trials in
developing countries have been conducted
in an ethical manner?

M3.01

June 2007

Box 1

Relevant sections from the Declaration of Helsinki

8. Medical research is subject to ethical standards that promote respect for all human
beings and protect their health and rights. Some research populations are vulnerable and
need special protection. The particular needs of the economically and medically
disadvantaged must be recognized. Special attention is also required for those who
cannot give or refuse consent for themselves, for those who may be subject to giving
consent under duress, for those who will not benefit personally from the research and for
those for whom the research is combined with care.
13. The design and performance of each experimental procedure involving human subjects
should be clearly formulated in an experimental protocol. This protocol should be
submitted for consideration, comment, guidance, and where appropriate, approval to a
specially appointed ethical review committee, which must be independent of the
investigator, the sponsor or any other kind of undue influence. This independent
committee should be in conformity with the laws and regulations of the country in which
the research experiment is performed. The committee has the right to monitor ongoing
trials. The researcher has the obligation to provide monitoring information to the
committee, especially any serious adverse events. The researcher should also submit to
the committee, for review, information regarding funding, sponsors, institutional
affiliations, other potential conflicts of interest and incentives for subjects.
19. Medical research is only justified if there is a reasonable likelihood that the populations in
which the research is carried out stand to benefit from the results of the research.
20. The subjects must be volunteers and informed participants in the research project.
22. In any research on human beings, each potential subject must be adequately informed of
the aims, methods, sources of funding, any possible conflicts of interest, institutional
affiliations of the researcher, the anticipated benefits and potential risks of the study and
the discomfort it may entail. The subject should be informed of the right to abstain from
participation in the study or to withdraw consent to participate at any time without
reprisal. After ensuring that the subject has understood the information, the physician
should then obtain the subject's freely-given informed consent, preferably in writing. If the
consent cannot be obtained in writing, the non-written consent must be formally
documented and witnessed.
23. When obtaining informed consent for the research project the physician should be
particularly cautious if the subject is in a dependent relationship with the physician or may
consent under duress. In that case the informed consent should be obtained by a wellinformed physician who is not engaged in the investigation and who is completely
independent of this relationship.
30. At the conclusion of the study, every patient entered into the study should be assured of
access to the best proven prophylactic, diagnostic and therapeutic methods identified by
the study.
The full Declaration of Helsinki is available at www.wma.net/e/policy/b3.htm.

5

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Do European registration authorities ascertain whether clinical trials in
developing countries have been conducted in an ethical manner?
M3.01
Wemos staff
June 2007

Wemos Foundation
P.O.Box 1693
1000 BR Amsterdam
The Netherlands
T +31 20 435 20 50
F +31 20 468 60 08
E info@wemos.nl
www.wemos.nl

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