LETTER FROM CHENNAI

misleading or otherwise unauthenticated, renders himself liableto disciplinary proceedings.

PROFESSIONAL MISCONDUCTThe MCI in its brochure on Code of Medical Ethics has given a listof a large number of acts which can be penalized by the Councilfor professional misconduct.' They include adultery with a pa-tient, conviction by a court of law for moral turpitude, issue offalse certificates and statements, contravention of the provisionsof Drugs Act or prescription of scheduled poisons for ulteriormotives, self promotion through advertisement in the press,refusal of medical aid on grounds of religion or nature of diseaseand disclosure of the confidentiality of a patient without hisapproval. The disciplinary action may include punishment asdeemed necessary by the appropriate medical councilor removalof the name of the practitioner from the register of the council fora specified period of time or altogether depending upon thegravity of professional or moral misconduct.'

CONCLUSIONSMedical practitioners are human beings and not demi-gods.Eminent academicians, medical practitioners and professionalbodies should assume a leadership role to launch a national move-ment against the degradation of traditional moral values andupsurge of unethical medical practices. The declining image ofthe medical profession needs a moral boost and rejuvenationthrough a process of soul-searching in the light of existing socialrealities. There is aneed to introduce regular education programmes

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in the field of behavioural sciences and medical ethics for gradu-ate and postgraduate medical students in all the medical schoolsof the country .12 The teachers must serve as role models, infuseand enthuse the qualities of compassion, sensitivity and genuineconcern towards patients and their attendants. When practisingphysicians are more considerate, cautious, honest and ethical intheir dealings with their patients, there should be no fear ofconsumer fora.

REFERENCESSingh M. The art and science of pediatric diagnosis. Indian J Pediatr 1995;62:681-6.

2 Medical Council of India. Code of Medical Ethics, 1970.3 Pellegrino AE. The metamorphosis of medical ethics: A 30-year retrospective.

JAMA 1993;269:1158-62.4 Ethical issues in perinatology. Natl Med J India 1996;9:32-7.5 Singh M. Ethical issues in perinatal medicine: Indian perspective. Indian Pediatr

1995;32:953-8.6 Singh M. Ethical considerations in pediatric intensive care unit: Indian perspective.

Indian Pediatr 1996;33:271-8.7 Blendon RJ, Szalay US, Knox RA. Should physicians aid their patients in dying?

The public perspective. JAMA 1992;267:2658-62.8 Burnum JF. Secrets about patients. N Engl J Med 1991;324:1130-3.9 La Puma J, Stocking CB, La Voie D, Darling CA. When physicians treat members

of their own families: Practices in a community hospital. N Engl J Med 1991;325:1290-4.

10 American College of Physicians. Guidelines for the physician expert witness. AnnIntern Med 1990;113:789.

II American College of Physicians. Ethics manual. Third edition. Ann Intern Med1992;117:947-60.

12 Singh M. Behavioural sciences and medical ethics for undergraduate students.Indian J Med Education 1994;33:30-4.

The average letter of referral is a routine thing. Increasingly, thepatient is told to go and see so-and-so, and is despatched withouta letter of reference ..This is hardly surprising in this age wheneveryone is in a hurry. Sometimes, though a letter is written, itmight as well not have been. 'To consult nephrologist.' Presum-ably anyone ofthe breed. And why? Let the nephrologist find outthe name and address of the doctor from the patient, so that thedoctor could send him some information about the patient inreturn.

I was pleasantly surprised to have a patient sent to me with aletter which was not merely informative, but was also a pleasureto read. I quote a couple of paragraphs from it: 'Except for theextreme anorexia, occasional drowsiness and relentless vomiting,she does not exhibit any intolerable itching, bloody diarrhoea, dryand coated tongue, uraemic jactitation, mental obtundation on thebrink of stupor as is common in end-stage renal failure. But thesinister rise in blood urea, serum creatinine and serum potassiumin a crescendo fashion are danger signals that alert the generalpractitioner, who has been accustomed to face death at anymoment. To bask on the conservative line oftreatment is to invitedisaster.

'Haernodialysis is imperative to save her life. What is thatsupercharged deluge of antigen that triggered the cascading

antigen-antibody reaction with the connivance of the comple-ment to unleash the infernal soluble immune complex to disruptthis patient's kidney, nature's architectural wonder revered bygenerations of medical connoisseurs as the watchful paragon inmaintaining the milieu interior of the body? Whether the ominousantigen has licked or bitten the glomerulus, basement membraneor matrix focally, diffusely, segmentally, globally, is within therealm of modem, mighty medical institutions to ward off the fatalcrescentic nephritis, and hence this letter of reference for yourdiscreet judgement and compassionate care of this forlornpatient.'

Time was when the physician was learned in the arts as well as thesciences. Some of the greatest writers have been medical men;Oliver Goldsmith, Somerset Maugham, A. J. Cronin, to name buta few. While these litterateurs gave up the practice of medicineand became full-time writers, there have been other famousmedical men who wrote, in the words of Dr Johnson, 'like angels'.William Osler was one of them. His collection of essays andspeeches, Aequanimitas, should be mandatory reading for allmedical students and doctors. I quote some of his sayings: 'Thedesire to take medicine is perhaps the greatest feature whichdistinguishes man from animals.' 'The natural man has only two

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primal passions, to get and to beget.' 'The greater the ignorancethe greater the dogmatism.'

Another practising physician and great writer was OliverWendell Holmes, a collection of whose essays appeared as Theautocrat at the breakfast table. 'The advice of their elders toyoung men is very apt to be as unreal as a list of the hundred bestbooks.' 'Nature, when she invented, manufactured, and patentedher authors, contrived to make critics out of the chips that wereleft.' And this gem in verse, 'Speak clearly, if you speak at all;Carve every word before you let it fall.'

The physician of today is a scientist or a technician, but hardlyever an artist. Yet our experience peculiarly equips us to pursuethe humanities, since we are exposed to the full range of humanemotions-worry, sympathy, grief, rage, and often when weachieve our goals, happiness.

The Transplantation of Human Organs Act, 1994 has been inforce in Tamil Nadu since 1995. A good number of cadaver organshave been harvested since then. Around 50 renal transplants,some cardiac and a couple of liver transplants have been done inChennai. Contrary to the anticipation of protagonists of the liveunrelated donor transplant, it has not been a stream of organs fromthe public hospitals to the rich in the private sector. Actually, onlytwo donors came from the government hospitals. Most were fromprivate hospitals, and some of the organs were given to patients inpublic hospitals. I have always felt that the better informed aperson, the more likely he or she would be to see the need fortransplantation and the donation of organs.

No thanks are owed to the Government of Tamil Nadu for thisearly success. There has been no attempt to educate the publicabout organ donation, and the government has not fulfilled itsobligation to set up a registry of intending donors and providethem with an organ donor card. What is worse, the AuthorizationCommittee which is supposed to ensure the correct working of theAct seems bent on subverting it. The preamble to the Act states:'Whereas it is expedient to provide for the regulation of removal,storage and transplantation of human organs for therapeuticpurposes and for the prevention of commercial dealings in humanorgans .. .' (emphasis mine). In the absence of a related donor, theAct provides for transplantation from people other than nearrelatives 'as is specified by the donor by reason of affection orattachment towards the recipient. .. '. This is the so-called emo-tionally related donor. It is hard to believe that large numbers ofsuch dear friends will be found in any society, and the majority ofunrelated live donors must be motivated by affection or attach-ment for money.

I spoke to one of the members of the committee. He said he forone was unable to deny that the donor was motivated by affectionfor the recipient. How could such affection spring up between theslum-dweller of Chennai and the millionaire from the North? Themember said: 'He says he truly cares for him. Who am I to say hedoes not?'

Acceptance of such donors by the Authorization Committeesubverts the spirit and meaning of the Act. As long as the rich andinfluential have a loophole to buy kidneys whenever they are inneed, they will not raise their voices to persuade others to donateorgans after death. While renal transplantation can always bedone from living donors, other organ transplants cannot be donein the absence of cadaver donation. The gratifying success of thecardiac transplants done in the country so far raise the hope ofgood life for these sufferers.

Recently, a VIP developed kidney failure. The machinery of

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. IO,NO.4, 1997

the Government of Tamil Nadu was set in action to find anunrelated donor for him. And this is the machinery which shouldbe enforcing the law!

I am reminded of the time I saw a police car making anunauthorized turn, crossing a double yellow line and endangeringthe lives of the other users of the road. I protested to the trafficconstable on duty, who watched these transgressions with abenign eye. How can you allow this, I fumed. He was genuinelypuzzled, 'But it is a police vehicle'. Lord Hewart (1870-1943),Britishjudge, said: 'Justice should not only be done, but shouldmanifestly and undoubtedly be seen to be done.' It is all the moreimportant that those who make our laws, and those entrusted withthe task of enforcing them, should show themselves to be law-abiding citizens. As long as we accept that some of us are moreequal than others, we will not progress.

The Government of Tamil Nadu quietly had a new Act passed inthe state legislature. It goes by the name of the 'Tamil NaduPrivate Clinical Establishments (Regulation) Act, 1997'. TheIndian Medical Association and a number of other professionalassociations rose in muted protest. All doctors were requested towear a black badge of protest on one day. This is a dignified formof protest, and is so much better than a strike, in that it does notcause harm to the community.

The badge bore the words: 'We oppose the Regulation Act. Wewant self-regulation only.' We have been free to regulate our-selves all these years, and what have we done? Pretty much whatwe please. Consumer courts have introduced some degree ofanswerability to the profession today, but misuse by the public hasrendered them in large measure ineffectual in changing thebehaviourofthe medical fraternity. Clearly there is need for someregulation. I therefore preferred to be a conscientious objector,and left my badge unworn.

I obtained a copy ofthe Act and read it. Had I known its contentbefore the day of the protest, I would willingly have worn thebadge. The statement of objects and reasons is unexceptionable.'In recent years there has been a mushroom growth of privatehospitals, nursing homes and other clinical establishments in thestate of Tamil Nadu and such hospitals, nursing homes and otherclinical establishments are run in an unorganized and haphazardmanner. At present, there is no law to regulate such privatehospitals, nursing homes and other clinical establishments. It hasbeen considered necessary that such private hospitals, nursinghomes and other clinical establishments shall be regulated andcontrolled by registration.'

I read avidly through the Act to find out what standards theGovernment of Tamil Nadu expected from the said private medi-cal institutions. There were clauses on the need for registration,the need for a certificate of registration, the threat of suspensionor cancellation of registration, the right of the 'competent author-ity' to inspect or inquire, a provision for appeals, the extent ofpunishment ('fine which shall not be less than five thousandrupees but which may extend to fifteen thousand rupees'), and thedefinition of who would be held responsible if the offender was acompany. But what should the private medical institutions do tosatisfy the competent authority (who is anyone appointed by thegovernment 'to perform the functions of the competent author-ity') that it was within the bounds of the law? That remains aclosely guarded secret. Can the competent authority take thedecision as he or she thinks fit? 'The government may, bynotification, make rules to carry out the purposes ofthis Act.' Thatseems to confer Draconian powers on the government. Would it

LEITER FROM LONDON

not be better in law for the government to come clean and spell outwhat it expects of the private hospitals?

I do not think any good will come from more governmentinterference. Perhaps, the government should first set its houseand the hospitals it runs in order before it looks to correct thedefects in all of us. I have no doubt that the petty functionariesappointed to oversee the new regulations can easily be disposedof with a small sop, and nursing homes will continue with theirpractices as before. How many of the blood banks in the countrysatisfy the conditions laid down for their functioning?

What is the answer? The Indian Medical Association submit-ted a memorandum to the Chief Minister, requesting the govern-ment to withdraw the Act. That is an exercise in futility, for thepublic is clearly in favour of some sort of regulation, and thepublic has more votes than the medical profession. I suggest weshould make our appeal to the somnolent guardian of our moral-ity, the Medical Council ofIndia. Please wake up and do the workyou were intended to do, like the General Medical Council of theUnited Kingdom. Set up clear guidelines for owners of hospitalsand nursing homes to follow in running such institutions, and setup the machinery to inspect and enforce these guidelines. The

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writing is on the wall. The less we do, the more will the public andthe government feel compelled and emboldened to intrude.

A young man came to me more than a year ago. He had mildglomerulonephritis and hypertension. I stressed to him the impor-tance of maintaining his blood pressure under good control, andasked him to return to me periodically for a check up. He was froma public sector undertaking not far from Chennai, and had excel-lent medical facilities available to him. His doctor had referredhim to me, and would look after him on his return, at no cost. Hewas back in my unit a month ago, unconscious, with cerebralhaemorrhage. He had married three months earlier. His wife wasunaware that he had any disease, and he never saw a doctor or tookany medicine since their marriage. He died.

The young widow was distraught. 'What will happen to me?'she wailed. 'Who will marry me? It is easy for you men. If a youngwife dies, the man will marry again, but no one marries a widow.Was it right of this man and his family to involve me in his lifewithout telling me he had a disease? Why should they have ruinedmy life? Why did not my father make proper enquiries beforetying me to him?'

I have no answer.

M. K. MAN!

In my last letter' I commented on an article suggesting that doctorsborn outside the United Kingdom died at a younger age than thoseborn in the UK.2 We all fell for a simple statistical error.

A letter in the BMF pointed out that the difference in the ageat death was due to 'inferring risk based solely on cases withoutdenominators' and reflected the different age structure of the twogroups. In Great Britain the percentage of the population aged60-74 years and above is higher among white people than in someother ethnic groups. The median age of 'whites', Indians, blackAfricans and black Caribbeans is 37,29,27 and 31 years, respec-tively. Doctors in these groups can breathe easier for a few moreyears. There has been an appropriate ingestion of editorial humblepie in the BM1.4

Selenium has been a much neglected dietary constituent of theEuropean diet. It has long been known that in certain parts ofChina with exceptionally low selenium content of the soil, therehave been endemic forms of cardiomyopathy (Kershan disease)and a deforming arthritis (Kashin-Beck disease),' but the sugges-tion that the European diet is deficient in selenium is new."

Selenium, in the form of selenoproteins, is an essential compo-nent of a number of enzyme systems which remove hydrogenperoxide and other hydro peroxides generated by free radicals. Ifthese are not removed membrane structure and function areimpaired, causing blood clotting disturbances and promotingatherosclerosis. Selenium is also necessary for the conversion ofthyroxine to triiodothyronine, for motility of spermatozoa and fornormal testosterone metabolism.

There is evidence that in Europe the intake of selenium isfalling, accompanied by a decline in the selenium content of theblood. In Britain, it seems to be due to a drop in imports ofselenium-rich high protein wheat from North America and fromchanges in bread-making technology. Nearly all farm animals inBritain are given mineral supplements containing selenium, andit is suggested that selenium should be added to flour or soilfertilizers.

The appearance of 'Dolly', the cloned sheep, has aroused apredictable controversy.' The original article pointed out thatDolly was the only successful outcome of 29 blastocyst/morulaetransfers to 13 surrogate ewes. Also, the phenotype of the originalcell supplying the transplanted nucleus is not certain. While it hasbeen assumed to be a mammary epithelial cell from a 6-year-oldewe in late pregnancy, it could have been an unmodified stem cell.However, as opposed to foetal cells, this is the first cloning froman adult cell. Dolly's future is uncertain. Will she have a normallife span or has the transferred DNA suffered a degree of ageing?Though there are potentially useful results from animal cloningsuch as elite forms of farm stock, or animals transgenically modi-fied to produce medically useful products, Britain and some othercountries have regulations banning the cloning of humans.

The profession continues to talk itself into rationing of resourcesand privatization of the National Health Scheme (NHS). A re-viewer of a major work on the NHS between 1958 and 1979 hascommented that 'the dream of free health care' has been under-