Paradigm shift in medical ethics

Paradigm shift in medical ethics

Dr KK Aggarwal

There has been a paradigm shift in the thinking of the public. There has been a corresponding paradigm shift in the dynamics of doctor-patient relationship; from paternalism to patient-centric. Today, patients want to be equal partners in decisions about their treatment with the doctor acting as a guide and facilitate decision making. Patient autonomy is also now at the forefront of the principles of medical ethics, along with non-maleficence (do no harm) and beneficence (do good).

From Vedic point of view, the public perception has rapidly shown a shift from Karma Marg to Bhakti Marg and to Gyan Marg. In Karma Marg, people surrender to the doctor-patient relationship. In the phase of Bhakti Marg, they show faith and Gyan Marg, is marked by suspicion and hunger to know why.

There are four types of patients today based on four levels of awareness i.e. their ability to retain knowledge or information that is given to them by the doctor pertaining to their disease. These four levels of awareness are “ignorant, informed, empowered and enlightened”.

• Ignorant patients do not participate in decision making and depend on the doctor to make their decisions, with no questions asked.

• Informed patients have questions for the doctor, but only few. These patients then usually agree to the line of treatment adopted by the doctor.

• Empowered patients have many more questions, they cross check facts and are an equal partner in decision making regarding their treatment.

• Enlightened patients seek the opinions of many are only then convinced about the proposed line of treatment. Convincing these patients involves several counseling sessions.

There can also be three types of doctors.

• Doctors who expect patients to accept what they say.

• Doctors give choices to patients and ask them to choose.

• Doctors who give choices to their patients, but help them to choose the best option.

Miscommunication is at the root of many doctor-patient disputes. This occurs when the level of awareness of doctor and the patient do not match.

There are also four types of students as per Rabbi Dovid Rosenfeld according to the ability to retain the knowledge taught to them: Sponge, a funnel, a strainer and a sifter.

• The sponge retains everything, but is unable to distinguish between correct and incorrect points. He lacks Viveka, the power of discrimination. The funnel is the one for whom information goes in one ear and out the other. With no focus, his hearing and the mind are in different directions.

• The strainer discards the wine (significant material) and retains the lees (incorrect or insignificant points). He remembers all sorts of trivial or useless details of the material he studied.

• The sieve retains the fine flour (significant material) and discards the dust (inconsequential details). He understands the lecture by its main points and remembers them in the form of sutras.

The principle of “suno – samjho – jano – karo” exemplifies this. This is also the gist of Vedic science and has also been clearly defined in Bhagavad Gita by Lord Krishna. We should hear, listen, understand and convert it into wisdom. Hearing means that you hear anything but listening means that you should learn its meaning. Understanding means you should understand its value in your context and wisdom means you should practice it, re-practice it and learn intricacies of its implications. Once knowledge has been converted into wisdom it is of no use unless it is made use of in day-to-day practice.

Similarly, there has also been a paradigm shift in the accountability for doctors. There was an era when self-regulation in the form of an oath was sufficient (Hippocratic and Medical Council of India [MCI] Oath). As this was considered insufficient, the Code of Medical Ethics Regulations came into force from 2002, which was rapidly followed by Consumer Protection Act (CPA), civil liabilities and now criminalization of medical practice including 304 A.

The Code of Ethics Regulations, 2002 is not simply an Ethics code; it is also about conduct and etiquettes. Unfortunately, ethics, conduct and etiquettes are not taught in the medical curriculum. It is also important to differentiate between unethical acts and professional deficiency.

Therefore, today one is not only required to be scientifically correct, but also morally, ethically and legally correct.

Individual ethics (dharma) or code of conduct (ethics in society) change according to society. Dharma (to hold people together) changes as per the collective consciousness of the people. As people are empowered, ethics will also change.

Disclaimer: The views expressed in this write up are entirely my own.

Paradigm shift in blood donation

Paradigm shift in blood donation India has huge population of more than 1.3 billion, but is still short of blood by 20-25%. Blood donation is a requirement of the society. All donations should be voluntary. Blood donation camps are often organized by hospitals and NGOs. But these are whole blood donation camps. But, now no camp should be organized for ‘whole blood donation’. Instead components-only blood donation camps should be organised. One unit of blood collected can be used to help 3 to 4 patients, instead it is being wasted as whole blood depriving another patient in need. And, voluntary blood donation camps should be now called “blood component donation” camp and not just blood donation camp. So, if the blood being donated is collected in a single bag, do not give blood. Usually two component bags are used. 100 ml bags should be promoted for pediatric use. People with rare blood groups should not donate in camps. They should instead donate only when needed. Under the new National Blood Transfusion Council regulations, no blood is to be wasted. The surplus left over plasma is fractionated to manufacture products like albumin and intravenous immunoglobulins (IVIG). The blood that is donated in voluntary blood donation should be maximally utilized. The tests done are for blood groups (A, B, O) and Rh factor and five transfusion-transmitted infections namely hepatitis B and C viruses, HIV 1 & 2, VDRL and malaria. Tests with the shortest window should be chosen as per affordability. For safe blood transfusion, tests other than those prescribed by the government should also be available such as minor blood groups, nucleic acid amplification testing (NAT). NAT detects very low levels of viral RNA or DNA that may be present in donated blood and reduces the window period of detection of viruses like hepatitis C, hepatitis B, HIV, which may otherwise be undetected by 3rd generation or even 4th generation ELISA-based tests. The prevalence of hepatitis B, C and HIV is very high in India. The doctor has a duty to inform the donor that facilities for these other tests are also available and the donor or the recipient should have the right to ask for extra tests. Till they a national policy is formulated in this regard, a doctor can help the donor or the recipient to decide. An informed consent must be taken from the donor or the recipient explaining the risks by not doing these tests, however small and rare they might be. These tests may add to the cost of the blood transfusion, but patient safety is foremost. The donor’s blood should also be tested for lipids, liver enzymes (SGOT, SGPT), kidney function (creatinine); a complete hemogram can be done, so that the donor gets a comprehensive panel of tests done, when he/she volunteers to donate blood. Rational blood transfusion is safe blood transfusion… Transfuse blood only when necessary. If only one unit is required, don’t transfuse blood; if two units are required, transfuse one. If hemoglobin is more than 7, give a trial of intravenous iron first. This is also a very important way by which the transfusion-transmitted infections can be reduced. Dr KK Aggarwal National President IMA & HCFI Recipient of Padma Shri, Dr BC Roy National Award,Vishwa Hindi Samman, National Science Communication Award & FICCI Health Care Personality of the Year Award Vice President Confederation of Medical Associations of Asia and Oceania (CMAAO) Past Honorary Secretary General IMA Past Senior National Vice President IMA President Heart Care Foundation of India Gold Medallist Nagpur University Limca Book of Record Holder in CPR 10 Honorary Professor of Bioethics SRM Medical College Hospital & Research Centre Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand Editor in Chief IJCP Group of Publications & eMedinewS Member Ethics Committee Medical Council of India (2013-14) Chairman Ethics Committee Delhi Medical Council (2009-15) Elected Member Delhi Medical Council (2004-2009) Chairman IMSA Delhi Chapter (March 10- March 13) Director IMA AKN Sinha Institute (08-09) Finance Secretary IMA (07-08) Chairman IMAAMS (06-07) President Delhi Medical Association (05-06)

A paradigm shift in the thinking of IMA this year

A paradigm shift in the thinking of IMA this year

IMA represents the collective consciousness of 2.8 lakh doctors across 1700 local branches and 31 state branches. To further strengthen the Association, this year we have envisaged a proactive role for IMA: moving on from what “IMA can do” to what “IMA Should Do” or “IMA to Do”.

We have also defined our guiding principles for this year. In 2017, IMA policies will be based on

·           Collaboration rather than cooperation

·           Right action and not convenient action

·           Good plans and not quick plans

·           Good Governance

·          Financial stability

·          Effective time management

·          From professional to community priority

Our endeavour would be a collaborative approach to problem solving or tackling issues and challenges, where, unlike in cooperation, we work together in partnership towards one common goal. A collaborative approach accomplishes more than what can be done at an individual level.

I ask all IMA leaders to close the eyes and imagine themselves as President of IMA for a minute and think of what they could do to help the organization and the community via the Association. And that is what they contribute to the working of IMA.

Give 2 minutes of your time every day to IMA and come out with ideas and plans and submit them to IMA HQs for review and possible implementation.

Right action taken at the right time yields the desired result, which is long-lasting. The path of right action may be tough, yet it is the one we choose to solve a problem, rather than a more convenient action. A convenient action gives immediate gains, while the right action may not give immediate results.

Our aim is not to meet short-term goals. Hence, we want policies to be guided by good plans, which lay down a solid foundation. Good plans increase efficiency of working, facilitate effective utilization of resources, provide direction, promote teamwork and are goal-oriented. The gains from a good plan trickle down generations. Hence good plans are not quick plans.

Governance simply means decision making and implementation of decisions. Good governance has 8 major characteristics as described by the United Nations Economic and Social Commission for Asia and the Pacific. It is participatory, consensus oriented, accountable, transparent, responsive, effective and efficient, equitable and inclusive and follows the rule of law.

Let us all follow these principles in one voice and make the Indian medical profession best in the world.  

Dr KK Aggarwal

National President IMA and HCFI

The Mosquito Menace: How to win over our collective failure

The Mosquito Menace: How to win over our collective failure

Dr K K Aggarwal
National President Elect and Honorary Secretary General IMA
President Heart Care Foundation of India
Napoleon Hill once said, “Most great people have attained their greatest success just one step beyond their greatest failure.” It’s time for all of us to convert our biggest failure of controlling the mosquito menace into success. We must all agree that collectively we have failed in controlling the mosquito menace and consequently, Delhi today is in the midst of an epidemic of Chikungunya with increasing numbers of dengue and malaria patients. This is a collective failure of Municipal Corporation, Delhi Government, Central Government, LG office, Medical Associations, CSR departments, Media, NGOs and Private sector. As per the current picture, the mosquito container index (the percentage of water-holding containers infested with larvae or pupae) in Delhi is over 40% and any index above 5% requires a community integrated cluster approach to reduce mosquito density together with effective anti-larval measures. But even today, 3 lakh mosquito repellent impregnated mosquito nets received by MCD as donations are not available to patients. Anti-larval measures, Temephos an organophosphate larvicide and/or mosquito fish or Gambusia, a freshwater fish are not available to a common man. What is the answer then? We need a paradigm shift in our thinking. We need to over report and act in time. There is no point acting when the cases have started. Often the civic bodies publically act in monsoon season. They may be planning ahead but public awareness and public involvement must start much ahead of time. Even the recent CAG report mentions that under reporting of dengue is disastrous to the society. We need to act against all the mosquitos, Aedes, Culex and Anopheles. Action against only the Aedes mosquito will not work. The campaign that Aedes mosquito is a day biter and only breeds in indoor fresh water will not work. Even if it is true, by killing Aedes you may end up in increasing the density of Culex and malaria causing Anopheles mosquitoes. Culex mosquito, which causes filarial and Japanese encephalitis is already rampant in the city. Even Aedes mosquito, which causes Chikungunya, West Nile, Zika and Dengue can spread by the bite of infected female indoor Aedes aegypti or outdoor Aedes albopictus mosquito. It is true that Aedes aegypti are more dangerous because they can fly up to 200 meters and only feed on human blood, whereas the Aedes albopictus that thrives outdoors can only fly as far as 80 meters and feed on animal blood other than human blood. The outdoor Aedes mosquito cannot be ignored. . The entire campaign up till now has been focused on a day biter, wearing long sleeves shirt and pants during the day and using night mosquito nets. But precautions needs to be taken throughout the day as the mosquitoes only recognize the light and not whether it is day or night. The fact that the mosquito only breeds in clear water also needs to be relearnt. The Aedes mosquito breeds in stagnant water anywhere inside or outside the house. Rain water is the most important source and can collect in any plastic container inside or outside the house. Even collected garbage in open areas can have left over plastic cups or tiny bottle caps with collected rain water collections providing an ideal atmosphere for mosquito breeding. It is true that disease spreading mosquitos do not make noise but the ‘noise-producing’ nuisance mosquitos unless addressed will not create a public movement. The law says that dengue or Chikungunya cases must be notified, but one can notify them within 7 days of diagnosis. Aedes mosquito takes up to three meals in a day and within 7 days will bite over 21 people in the vicinity. Municipal anti-mosquito and anti-larval actions must occur within hours of its detection. The very purpose of notification is lost if the disease is not notified within hours of even suspecting a diagnosis of Chikungunya. So, all suspected cases must be reported without waiting to confirm the diagnosis. We have failed because the government has been insisting that only ELISA-confirmed cases be notified. An SMS should be sent to all doctors practicing in that PIN code areas with a case so that they can become a part of the public health action chain. When the first case is suspected in a state, colony or house, all public health measure should start. An SMS should go to local councilor, MLA, MPs, all practicing doctors, local chemists, NGOs, RWAs, local IMA Branch, State IMA Branch, IMA Headquarters and other Specialty Organizations to join the public health chain efforts. It has taken over a decade for us doctors to understand that dengue 1 and 3 strains are not dangerous and cause only platelet deficiency with thinning of blood, while dengue 2 and 4 strains are dangerous as they destroy platelets and thicken blood due to capillary leakage and rise in hematocrit. Also, that platelet transfusion is not required in absence of active bleeding and it is the timely fluid resuscitation that is more important and not platelet resuscitation. Dengue becomes serious when the fever is subsiding. Earlier, dengue patients with high fever were hospitalized and there was always an urgency to discharge them when fever was subsiding. Now we know that the machine reading of platelet count can be defective. There can be an error of 20%. A platelet count of 10,000 by machine reading can mean it is actually 50,000. Hospital beds should be reserved only for severe dengue and severe Chikungunya cases. Just because one can claim reimbursement in Mediclaim or PSU, should not be the factor to decide on hospital admission. If it was US, Medicare by now would have come out with admission guidelines. The message has been going that fogging has no answer. But at this stage of container index of > 40, we need not only ground fogging but also aerial fogging. When Zika threat came up in Brazil they deployed the army to join and make it a public movement. All political parties reach every house during election process, then why can’t each one of them reach every house and make the anti-mosquito and anti-larval measures effective. Breeding checkers are only with Municipal Corporations and they also have regulatory powers to impose fine. We need breeding checker in private sector. The Skill development Ministry should start courses so that anyone can hire a breeding checker on weekly basis to check their premises. Community approach involves that 100% of the society talks about dengue. Every premise must write that their premises are mosquito-free. When you are invited to somebody’s place, you should ask “I hope your premises are mosquito-free” and when you invite somebody, write “Welcome to my house and it is mosquito-free”.’ Even today most hospitals do not provide mosquito nets to dengue or Chikungunya patients. While they may be having anti-larval mesh doors or mesh windows but for secondary prevention of dengue or Chikungunya, we need to ensure that medial establishments are certified mosquito-free. Many of us live in flats and the mosquitoes may be breeding on the roof top belonging to one of the owners of the flats and if he/she is out of station for a holiday, the anti-larval measures may remain deficient. RWAs should use their powers to check all unoccupied or closed premises including hostels, hotels and construction places in that premises. One of the five great vows of Jainism is Non-attachment/Non-possession or Aparigraha. It talks about not storing unwanted things. But in today’s era our roofs and verandahs are littered with left over tires, utensils, plastic utensils etc. We buy new car tires and keep the old ones on our roof top. We need to change this habit. We have forgotten to plant Tulsi and Peepal in our premises and stopped the daily Yagna, all of which have anti-mosquito properties. The new strategy has to focus on small collections of water such as bottle caps, finding mosquitoes lower in the room under the table or the bed, to look for them in all three parts of the house - roof tops, verandahs and inside the rooms including unused toilets accessories. Also the slogan “Check your house once a week” needs a change. One should be alert every day. It should be a part of your routine. You do not clean your premises once a week. Make it a habit to look for the breeding places. The new approach should be a war against indoor or outdoor mosquitoes; fresh stagnant or dirty water mosquitoes; small containers like bottle caps or large containers like overhead tankers; made of mud or plastic; throughout the day (early morning fogging when pupa hatch for Aedes, late night for malaria); scrubbing clean the utensils Slogan: Ghar ke ander or ghar ke bahar; din me or rat me, deewaron ke niche or upar, chote pani or bade pani ke collection me, eggs larve or mosquito, teeno ko maro.

Paradigm shift in Aedes Mosquitoes over the last decade

Paradigm shift in Aedes Mosquitoes over the last decade​

Dr K K Aggarwal

 

Then - It bites only in the day.
Now - It bites in the light. Day and night does not matter.

Then - It breeds in safe water.
Now - It breeds in stagnant water from natural sources.

Then - It breeds only inside the house.
Now - It breeds both inside and outside the house, in any discarded objects/containers with stagnant rainy water collection.

Then - Mosquito breeds in water tanks on the roof and coolers.
Now - It breeds both in small and large water collections. It can even grow in the caps of bottled water.

Then - Mosquito grows high in environment.
Now - Mosquito grows low in environment. Look for it lower in the walls.

Then - Mosquito nets are not needed to prevent dengue.
Now - When you sleep during day or night, use mosquito net during an outbreak.

Then - You only need to notify the confirmed cases.
Now - You also need to notify suspected cases

Then - Mosquito can lay eggs anywhere.
Now - Mosquito does not prefer to lay eggs on earthen utensils.