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Comment on: "The minister of health, the director of AIIMS and Shah Rukh Khan"
This refers to the write-up "The minister of health, the director of AIIMS and Shah Rukh Khan" (1) appearing in July-September issue of the journal. While freedom to articulate views is a basic tenet of a healthy democracy it does not give the authors a right to make unsubstantiated allegations against a highly respected cardiothoracic surgeon ºwho served the nation all his life. The authors allege, without substantiating, that the then director of The All India Institute of Medical Sciences provided support to those agitating against caste based reservations. Where is the evidence to support this comment? When did the director come out to support the agitators?
The only basis for the authors to conclude that Dr Venugopal was supporting the anti-quota agitation probably stems from his reluctance the use barbaric methods to evict medical students who were protesting in a Gandhian manner. One may or may not agree with the agenda of agitators but nobody can deny the fact the agitation was a peaceful one and any use of force, as done by Mumbai police (2), would not have been justified. It will be much better that the authors use evidence rather than hearsay, and facts rather than fiction, to buttress the statements they choose to make.
Vishal Sharma, resident, department of medicine, University College of Medical Sciences, New Delhi INDIA e-mail drvishal82@gmail.com
References
1. Thomas G, Srinivasan S. The minister of health, the director of AIIMS and Shah Rukh Khan. Indian J Med Ethics 2008;5:106-7
2. Bhatia R. Police beat up medicos. Daily News and Analysis 2006 May 14. Available from http://www.dnaindia.com/report.asp?newsid=1029206
Authors' reply
Dr Vishal Sharma has raised a single objection to our editorial, that the statement: "Dr Venugopal had incurred the displeasure of Dr Ramadoss because he had supported students who agitated against the reservation of seats for Other Backward Classes in AIIMS" is unsubstantiated. Dr Venugopal's support of the agitation was a finding of the Thorat Committee Report as reported widely in the press. We provided a reference to one such press report (1).
However, this is not the main point of the editorial with regard to Dr Venugopal. The main point is that as Director of AIIMS, he did little to fulfil the aims of this special institute which is funded entirely by tax-payers' money.
Reference
1. Press Trust of India. AIIMS row: Sequence of events. Ndtv.com 2008 May 8. [cited 2008 Jun 27 and 2008 Sep 7]. Available from:http://www.ndtv.com/convergence/ndtv/story.aspx?id=newen20080049259
Stem cell quackery
An excellent article (1) by Sunil K Pandya on the use and misuse of stem cell therapy due to lack of legislation.
China and Korea have relaxed laws on this. I was surprised to read on the Internet that more than 50 per cent of patients in China in hospital for stem cell therapy are from the United States or countries in the European Union. In fact, there are agencies in Delhi arranging for stem cell treatment in China for patients willing to go over there. On the positive side, I met three patients who had come back from China after therapy, and who feel much better and they say they would recommend it to other patients too.
All is not lost in India. All that we require is stringent laws governing the use of stem cells. Guidelines cannot replace legislation. We have enough resources for stem cell therapy in India and if properly governed we can do wonders for our patients. If not, quackery will take over in the garb of clinical trials.
M Chandrashekhar, D-413, Ram Vihar, Sector 30, Noida 201 303 UP INDIA email:mchandrashekhar@hotmail.com
Reference
1. Pandya Sunil K. Stem cell transplantation in India: tall claims, questionable ethics. Indian J Med Ethics 2008; 5: 15-7.
Admissions under the Mental Health Act 1987
The Mental Health Act 1987 applies to all psychiatric hospitals run by the state or central government as well as by private and voluntary sectors with facilities for outpatient treatment and registered with the appropriate licensing authority. Admission procedures for patients with psychiatric illnesses in the MHA 1987 come under three categories: voluntary admission, admission under special circumstances, and reception orders issued by magistrates.
In the case of voluntary admissions, a large proportion of patients request their own admission and sign a form stating that they are willing for admission and treatment. This is ethically questionable as many of them suffer from illnesses which can impair their capacity to make an informed choice about seeking treatment. Some may lack insight into their illnesses. There is no mention of capacity assessment in these patients and many of them sign the form not knowing what they are signing, or under the pressure of family and treating professionals. They may then be given depot medication, restrained, given ECT or medication mixed in food and drink.
Patients who come in voluntarily can request discharge at any time from hospital. The medical officer has 24 hours to decide on the request for discharge. If it is felt that the patient cannot be discharged, the medical officer must apply to a medical board which can sanction a further 90 days' stay in hospital.
In my years of psychiatry training and practice between 1998 and 2004 in India, I did not see a single referral going to this "medical board". I am not even sure whether such a board exists. Normally what happens is that patients who want to go home are restrained, sometimes with the help of relatives, and given medication to calm them down, in their "best interests" as deemed by the treating professionals.
There are serious ethical issues here. Patients who may lack capacity can sign a form saying that they are seeking treatment voluntarily. But when they wish to be discharged they are prevented from signing themselves out without a referral to the medical board.
Patients may refuse to come into hospital informally can be admitted against their will on the request of their relatives or a friend. This needs to be supported by two medical certificates in the prescribed form.
This constitutes a minority of admissions for various reasons. Psychiatric hospitals generally prefer patients coming in voluntarily as it avoids the hassle of getting two medical certificates. So patients are forced to sign on a piece of paper they know nothing about, thereby becoming a voluntary admission.
It is ethically questionable how a friend can request admission for psychiatric treatment for somebody else. This psychiatric treatment can include parenteral medication as well as ECT. There is no definition of a "friend" as well in the Act. There is no provision for punishment of these "friends" if they are found abusing this provision of the Act.
There are no legal safeguards in the Act protecting these patients admitted against their will. There is no independent body looking into the admission procedures.
There is no role for a social worker in the Indian situation. This has been substituted by a relative or a friend making the act liable for abuse.
There is no legal provision in the Indian mental health act for treatment against patients's will.
Admission under special circumstances on request of a friend should be taken away completely and replaced by an application made by a trained social worker in mental health and to be supported by two medical practitioners independently. Detailed assessment of mental capacity needs to be done before patients are accepted as voluntary patients.
Audits need to be carried out at psychiatric hospitals across the country to see whether provisions of the existing MHA 1987 are implemented fairly. Stringent punishment should be meted out to those violating the law.
The Indian Psychiatric Society has been debating the act for several years now but nothing has happened in the last 15 years.
Medical professionals as well as people in authority need to acknowledge deficiencies in the current act and address them to safeguard the rights of this vulnerable group of patients. The government needs to make sure that the Act is implemented across the country in a uniform fashion. Psychiatrists, human rights activists, social workers and lawyers need to work in partnership and come up with an amended version of the Act as soon as possible.
Rajesh Jacob, consultant psychiatrist, Kettering Community Mental Health Team, Northamptonshire Healthcare NHS Trust, Northamptonshire, UK NN15 7HH rajeshjacob2005@yahoo.co.uk
Reference
1. National Human Rights Commission, New Delhi. [Homepage on the Internet]. The ministry of law and justice, government of India. The Mental Health Act, 1987. Published in The Gazette of India 1987 May 22. [cited 2008 June 4]. Available from: http://nhrc.nic.in/Publications/Disability/annexure3.html
Why should doctors go to rural areas?
I often read that doctors are not ready to go to rural areas, and many patients die because the medical officer is not available. Laws are being made to compel doctors to work in rural areas.
Since I became a doctor in 1975, there has been no change in the scenario of primary heath centres, which are fast deteriorating into post offices where cases are registered and transferred to higher centres. No emergency medicine and facilities are available. The medical officers who do stay are busy with their private practices. Committed doctors become frustrated with the government's priorities. I worked as a medical officer for 14 years. At the primary health centre in Birwadi, then in Kolaba district, I studied the scorpion sting in detail and reported my findings. I would spend 50% of my salary on phone calls to Mumbai and Pune for expert advice on people admitted to hospital for scorpion stings. The director of health services forced me to work on the target for family planning cases. Ultimately I got a transfer to Pune where I registered for MD. After completing my MD, in 1982, I got myself transferred to a primary health centre at Poladpur in Raigad. I was warned to leave government service as the majority of officers were corrupt and nobody would protect me for honest service.
Since 1983 I have suffered various ailments for which I have no choice but to go to Mumbai or Pune for treatment. My physician classmate who also worked in a rural posting had an acute myocardial infarction. As the lone physician in the area, he read his own ECG, advised his staff to give him streptokinase and died of reperfusion arrhythmias.
My children do not get a good education in rural areas. What facilities does the government give doctors who do stay in rural areas and do life-saving work? This question remains unanswered
H S Bawaskar, Bawaskar Hospital and Research Centre Mahad District, Raigad, Maharashtra 402 301 INDIA e-mail:himmatbawaskar@rediffmail.com
