Letter from Chennai

Speaking of medical ethics

If you come across a group of doctors speaking about ethics, you will generally find that the speaker and the listeners are senior citizens. Younger members of the profession regard this as an irrelevant topic debated by people in their dotage. I was pleasantly surprised to be invited by two groups of younger people to speak on ethics to medical students. One was to the entire student body of a college. I spoke to them in an 800-seat auditorium, which had only standing room left. They probably thought this would be a welcome diversion from their usual classes. When I called for questions and comments, to my disappointment, there were none–not one.

The second invitation came a few days later, and was to a smaller gathering and a less grandiose affair. A young couple (I would say an odd couple, but only in the sense of being unusual doctors) came to meet me. These youngsters have devoted their lives to community medicine. Dr B. Subhasri, obstetrician and gynaecologist, has done impressive work on maternal mortality in the community. She is now the clinical director of the Rural Women's Centre in Kanchipuram. Her husband, Rakhal Gaitonde, is mainly concerned with environment and occupational health issues. He works with the National Rural Health Mission in Tamil Nadu, chairs the community advisory board of the National Institute for Research in Tuberculosis, and is a part of the National ASHA mentoring group. He has registered for a doctoral degree. Rakhal also works with the department of humanities in the Indian Institute of Technology in Chennai.

In interactions with medical students of the city colleges, Subhasri and Rakhal felt there was no awareness of aspects of medicine other than rote learning of standard examination material. On their own, they felt they should help students to derive a broader view of medical practice, and so they invited me to speak to a group of students on medical ethics, and Dr Arjun Rajagopal to speak on evidence-based medicine. This little meeting was not under the auspices of any society or group. They merely spoke to a few teachers in the city colleges, asked them to spread the word, and put up a couple of notices. The meeting was held at the Tuberculosis Research Centre, not easily approached by public transport, and was scheduled to last from 5.30 to 8.30 p.m. Neither the organizers nor the speakers were sure we would have any audience, and I was pleasantly surprised when some 40 or 50 students turned up to spend three hours on something that would be of no value to them in their examinations. There were some searching questions, and one young man charged me with being false to my own declared principles when I admitted to falsifying a report to disqualify a potential live-related donor who had told me in confidence that she actually did not want to donate her kidney but hesitated to say that to her family. I have alway s spoken to every potential donor in private to ascertain whether consent was wholehearted, and have always offered this way out. Not all in medical ethics is clearly black or white. The question of aborting a foetus with an obvious anomaly that would lead to a life of misery is one example. One case discussed extensively in the British Medical Journal in the 1990s is another example. One young man used to pack condoms full of banned drugs and swallow them just before crossing the channel into England. He would sail through the customs, then head to his home, pass the condoms in the toilet the next morning, wash and repack the drug and sell it on the street. One day his luck ran out, he digested the condom and had a massive overdose of the drug. He was hospitalized and saved after a stormy illness. The doctor looking after him did not report him, feeling the confession of drug smuggling was a privileged communication, but the medical students reported him to the police on the grounds that if he was let off he would go back to smuggling drugs and lead so many more young men and women into addiction. There is no clear answer as to what we should do and it is good that the profession should discuss such questions, and learn to think of what is right and wrong.

The Medical Council of India has its list of commandments which all new graduates have to read, and then attest as follows: ‘I make these promises solemnly, freely and upon my honour.' That is a requisite for registration with the Council. That is barely a framework. We come across many situations in professional life that are not specifically covered by any published code. These need to be discussed by the teacher with his trainees when they arise, just like clinical problems. Just as a student imbibes the practical approach of his teacher, he will learn the ethics of his teacher's practice, or the lack of it. Example is always better than precept. Are we teachers of today up to it?

Youth is the time for idealism. It has been a disappointment to me that most medical students are intent only on obtaining a degree, by merit or otherwise, and do not care for anything else. The qualification opens the door to a lifetime of earning. I am delighted that there are some doctors of the future who care for the higher aspects of medicine, and am most grateful to Subhasri and Rakhal for their efforts to bring more meaning into these young lives.

The Continuing Saga of Violence Against Doctors

The Tamil Nadu Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage or Loss to Property) Act of 2008 has been of no use. Violence against doctors continues in Tamil Nadu, as it does all over the country, and the authorities do not take prompt action under the law. Justice delayed is justice denied, and does not have a deterrent effect. The staff of the Rajiv Gandhi Government General Hospital in Chennai have suffered on more than one occasion. This is a very busy hospital, and the junior doctors bear a tremendous load. Every patient and his relations think he is the most important person around, and expect him to be attended to first. However critical the condition of a patient, and however much attention has been bestowed on him, if he does not improve dramatically, they accuse the doctors and the hospital of negligence, and assault them indiscriminately. After one such incident, all the junior doctors went on strike one day in March. Just abstaining from work might not have had much effect, but they took more decisive action. The hospital is locatedjust across the road from the Central Railway Station, and the major bus routes running from the city westwards go down this road. The striking doctors sat down on the road, filling it from sidewalk to sidewalk and forming an impenetrable barrier to traffic. The government had perforce to respond immediately. The health secretary spoke to the hospital authorities and the striking students. He agreed to install closed circuit television cameras at every entrance and in the emergency rooms, the trauma wards and the intensive care units. The strikers demanded additional security arrangements on a permanent basis, wanted only two visitors to be admitted with each patient, and insisted that anyone using threatening or abusive language, or indulging in disorderly or violent behaviour, should face immediate action under the Act. The government accepted all the demands. Of course, history teaches us that verbal acceptance does not translate into prompt implementation, and the students may have to resort to follow-up road rokos before long.

Should the authorities have to be forced to take such measures? Should they not be concerned about the fate of hospital staff, some of whom have been seriously injured? Should these measures not have been introduced years ago, as soon as the need for this Act arose? Sadly, senior administrators in their air-conditioned offices in the secretariat hardly care about the plight of their lesser employees. I am firmly with President Calvin Coolidge who declared in 1919 that ‘there is no right to strike against the public safety by anybody, anywhere, any time’, and any strike by doctors, especially in government institutions, will endanger public safety. Should we not add that no government has a right to endanger the lives of any of its employees anywhere, any time, except perhaps in war? When government callously ignores the dangers to its doctors, what else can they do?

National Eligibility and Entrance Test (NEET)

NEET is a neat acronym, but it is not popular in Tamil Nadu. For several years, Tamil Nadu has lowered the standards of its State Board examinations. Admissions to professional courses are based on the marks obtained in these examinations, and no separate entrance tests are held. Where common entrance tests are held, as for the Indian Institutes of Technology, our share of the seats has fallen precipitously as our students cannot compete with the better educated students from other states and those who follow the Central Board of Secondary Education system. We rank last among the southern states. Some educationists claim that is because schools in other states, particularly Andhra Pradesh and Telangana, orient their classes to the requirements of entrance tests.

Be that as it may, students of Tamil Nadu are not confident of competing with the rest of India, and want to retain the old system of using local examination marks for admission, with large numbers of seats reserved under various categories. The situation is confused. Bonus points are given to applicants for postgraduate seats who have been in government service, varying according to the years of service and with weightage for having worked in backward areas. Under NEET, 50.5% of seats are reserved under various categories for undergraduate studies, but Tamil Nadu has 69% reservations, and our students want to retain this privilege. The government passed two bills exempting Tamil Nadu from NEET, but these bills have yet to get presidential assent. The Central health minister announced that there would be no exemption for Tamil Nadu from the provisions of NEET, and the examination was held on 7 May 2017. Last year, exemption was granted at the last moment, and some of our students remain in that hope. Meanwhile, close to a 100 000 of students from the state registered for the examination.

I am convinced that students from every state should compete on equal terms, and, if our students are not good enough, we should take another look at our system of education and see what we can do to make it better than the rest, as it used to be. Mediocrity should never be our goal.