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CorrespondenceTHE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 6, NO.2

The Transplantation of Human OrgansBill 1992

Sir-This long-awaited bill (no. LIX of 1992introduced in the Rajya Sabha) is of vitalinterest to the medical and legal professions. Itaims to provide for the regulation of removal,storage and transplantation' of human organsfor therapeutic purposes. More important, itproposes to prevent trade in human organs.

When passed, the law will apply only to theunion territories and the states of Goa, HimachalPradesh and Maharashtra (as these are the onlystates to have passed resolutions on such con-trol). Other states will have to adopt the lawbefore it can be enforced in them.

Medical and legal experts need to make con-certed efforts to ensure that the proposed act ismade applicable in the other states so thatuniformity prevails throughout the country.

Clause 2 (f) under Chapter I (p. 2) suggeststhat the law will permit removal of organs onlyfrom individuals above the age of 18 years.Since clause 3 (7) under Chapter II permitsparents of any person under the age of 18 topermit removal of organs for transplantation,the term defined in the earlier clause [2(f)under Chapter I] should read 'voluntary donor'instead of 'donor'.

The proposed law uses the criterion of brain-stem death to judge the point at which theremoval of organs for transplantation can beconsidered.' It defines brain-stem death as 'thestage at which all functions of the brain-stemhave permanently and irreversibly ceased. 2 Thenext definition is likely to lead to confusion.'Deceased person means a person in whompermanent disappearance of all evidence of lifeoccurs, by reason of brain-stem death or in acardio-pulmonary sense ... 3 Since the Act isconcerned only with removal of organs fortransplantation, the phrase 'or in a cardio-pulmonary sense' is best deleted.

~The definition of 'hospital lso needs re-thinking. As proposed in the bill, it embraces 'anursing home, clinic, medical centre, medicalor teaching institution for therapeutic purposesand other like institution'." Chapter Y (Regis-tration of Hospitals) notwithstanding, such adefinition is so riddled with loopholes as topermit the meanest of institutions to claimshelter under it. The capabilities of those keento make a fast buck make tightening of thisdefinition mandatory so that removal of organsis only permitted in large teaching hospitals andfully equipped private hospitals with more than100 beds. The restriction under Chapter y5should, in fact, be included under the earlierclause defining a hospital. 4

Clause (6) under Chapter II also makes sucha definition mandatory. It is highly unlikely thatany hospitals other than those referred to abovewill have the facilities for ensuring that nomistake is made in the diagnosis of brain-stemdeath.

Clause (2) under Chapter II is welcome. It

permits the person lawfully in possession of thedead body of the donor to grant all reasonablefacilities to a registered medical practitioner forthe removal of organs for transplantation, thusrespecting the wishes made earlier in writing bythe deceased. To avoid dispute, which mayrender the organs unsuitable for transplanta-tion, this clause should make it mandatory forthe person lawfully in possession of the deadbody to contest the will of the deceased only onproduction of written and witnessed proof thatthe donor had subsequently revoked his deci-sion to donate organs.

Clause (6) under Chapter II needs furthertightening. The criteria for the diagnosis ofbrain-stem death must be defined here and notleft to central or state governments (assuggested)" or by the committee to be consti-tuted as per this clause. Internationallyaccepted criteria for such a diagnosis are freelyavailable and should form a basis for the defini-tion. The committee constituted should only bepermitted to lay down guidelines on the exactprocedures to be followed before brain-stemdeath is certified using the defined criteriaprovided by the act.

Clause 5 (1) on page 5 refers to unclaimedbodies. It appears to serve no purpose except toallow removal of bone as all other organs arerendered unsuitable for transplantation withina few hours of death. The object of this clauseshould be clarified.

Clause 9 (1) under Chapter II (p. 6) is wel-come. It deals with removal of an organ fromthe body of a donor before his death and hasobviously been framed to prevent the obnoxiouspractice of renal transplantation into unrelateddonors for profit. Subsections (2) and (3) clarifythe situations when the organ has been removedfrom a dead body.

Clause 9 (4) (a) and (b) need further qualifi-cation. The act must specify who can beincluded on authorization committees by centraland state governments. It is essential that theseshould be only experts of unimpeachable inte-grity and competence in medicine, law andsocial sciences.

Subsection 10 (2) under Chapter III (p. 7)should include other bones (such as the iliaccrest and ribs) in addition to the eyes and theears. This will facilitate the development ofbone banks.

Clause 12 under Chapter III (p. 7) needsfurther qualification. It must ensure that themedical practitioner takes all the necessary pre-cautions so that no harm befalls the recipient asfar as is possible under the state-of-the-art oforgan transplantation at the time. The currentprevalence of the acquired immune deficiencysyndrome and the possibility of slow virus infec-tion of neural tissues are two examples wheresuch precautions are mandatory.Offences and penalties' for malpractices are

too mild. A fine of ten thousand rupees is nopenalty whatsoever when the sums to be gainedrun into hundreds of thousands of rupees. To

be an effective deterrent, the sum must beraised considerably, perhaps to a minimum ofone hundred thousand rupees. Likewise, con-sidering the fact that an organ transplant can bea matter of life and death, imprisonment for aterm which may extend to five years is laugh-able. Rigorous imprisonment for a much longerduration is needed to 'give teeth' to. the act.A provision for leniency by the judge underexceptional mitigating circumstances willensure that undue harm is not done to anunwitting offender.

10 March 1993 S. K. PandyaDepartment of Neurosurgery

K.E.M. HospitalBombay

REFERENCES

Bill No. LIX of 1992entitled 'The transplantationof human organs bill, 1992'. Chapter II, (5) p. 4.

2 Ibid. Chapter I, 2 (d) p. 2.3 Ibid. Chapter!, 2 (e) p. 2.4 Ibid. Chapter I, 2 (g) p. 2.5 Ibid. Chapter V, 14 (3) p. 8.6 Ibid. Chapter VII, 24 (b) p. 11.7 Ibid. Chapter VI, 18 (1) p. 9.

Scientific Dishonesty in IndianBiomedical Research

Sir-There have recently been an increasingnumber of reports on major frauds and thefading moral values of biomedical science, bothin the medical as well as the lay press. We there-fore read with great interest and concern apaper by K. Satyanarayana' and views of otheracademicians--' published in your journal.

Cheating in medical research is not uncommonin our country, though there are not manyrecorded episodes in the literature. This ismainly because we do not have the propermachinery to unravel such shameful acts.Exposure of fraud is taken to be in bad taste bysome scientists but if this state of affairs isallowed to continue it will ruin not only medicalscience but our entire health system. Therehave been several recent instances in our countrywhere scientists have indulged in major fraud-either fabricated research data or performedother serious unethical acts." These include:false claims made by a Delhi group of scientistsof having developed an antileprosy vaccine;three doctors in Calcutta claiming to haveproduced a test-tube baby; and submission ofa fake thesis by a biochemist of RajasthanUniversity. In 1989, a doctorate was virtually'bought' from Guru Nanak Dev University inAmritsar in a record time of 12 days by a resi-dent of England' using fraudulent means.There was alleged connivance in this by threefaculty members and a Deputy Registrar. Wehave recently been told by a colleague that areferee, who had been sent a 'case report' by a

CORRESPONDENCE

medical journal for peer-review, changed somecontents of the 'case' and submitted it toanother medical journal as his own work. Theconcocted case report appeared earlier than theoriginal one. The matter only came to lightwhen one of the original author's postgraduatestudents presented the concocted case reportin a journal dub. We believe that such casesof fraud are not uncommon in almost all ourmedical colleges.

A serious act of falsification has recentlycome to light. According to a report whichappeared in a popular fortnightly magazine.san academic fraud was committed in the pres-tigious Postgraduate Institute of MedicalEducation and Research, Chandigarh, when afalse claim of having cultured the herpes zostervirus was made by an Additional Professor ofthe Department of Dermatology along withsome other faculty members of the Institute.The sad part of this story was that it wasreported that the Head of the Department, whodiscovered the fraud had to resign while theindicted faculty member stayed on because, itis alleged, of his use of political contacts. Incontrast, in developed countries, there is closescrutiny of such cases. If a commission ofinquiry finds some truth in an allegation offraud, the culprit is severely censured. In India,such practices are so common that they areignored. If somebody tries to unearth falsifica-tion, there is ample chance that the accusermight have to vacate his or her official position.

'Low level' dishonesty is also rampant inIndian medical research. Unethical practicesinclude undertaking poorly designed studies,duplicate papers, slicing a research study intoseveral pieces to increase the number of publi-cations, omission of findings contrary to thegeneral results and hiding inconvenient facts.Medical faculty in our country depend mainlyon postgraduate theses of doubtful veracity fortheir routine research publications. We believe

, that major fraud is more often committed inresearch institutes whereas 'low-level' dis-honesty is more prevalent in medical colleges.Many factors motivate these acts, and includethe declining moral values of scientists, poorbiostatistical consultation, fading work-culture, the acceptance of gifts by doctors fromdrug companies? and the lack of strong ethicscommittees at both institutional and nationallevels. .

We should take urgent and effective steps tocheck these practices. Scientists of the statureof A. S. Paintaf and Raja Ramanna" havepublicly drawn attention to the fraudulence ofsome of our research, the poor quality ofour papers and bemoaned the indulgence inunethical practices by many of our well placedscientists to achieve important positions.21 February 1993 B. L. Verma

G. D. ShuklaDepartment of Biostatistics

and PsychiatryM.L.B. Medical College and Hospital

JhansiMadhya Pradesh

REFERENCES

Satyanarayana K. Fraud in biomedical science.Natl Med J India 1992;5:34-6.

2 Deo MG. Hope for Indian science. Natl Med JIndia 1992;5:252-3.

3 Kumar A. Fraud in biomedicalscience.Natl MedJ India 1992;5:243.

4 Gupta YP. Cheating in science. The HindustanTimes 1987Oct 15.

5 Anonymous. Attempt to buy doctorate. TheHindustan Times 1989Oct7.

6 Sandhu K. Overlooking ethics. India Today11992Sep30.

7 Chen MM, Landefeld CS, MurrayTH. Doctors,drugcompaniesandgifts.JAMA 1989;262:344&-51.

8 Anonymous. Ramanna cautions on governmentmeddling.The Hindustan Times 1991Ju128.

Supreme Court Judgment onSelf-financing Colleges

Sir-In a historic judgment the Supreme Courthas shown a pragmatic outlook and a commend-able grasp of the ground realities prevailing inIndia. The learned justices have addressedthemselves single-mindedly to the difficult taskof studying the different issues involved regard-ing private professional colleges and capitationfees.

In 1953, Dr T. M. A. Pai started the first evermedical college based on the sound principlesof 'self-financing'. At that time there were only32 medical colleges in this country and he knewthat hemmed in by a shortage of resources andan increasing population, the governmentcould not afford to meet' the ever 'increasingdemand for professional colleges. He also knewthat collecting large donations to meet the out-lay necessary for a professional college wouldbe impossible. There was little option thereforebut to make parents pay for the education oftheir wards. Dr Pai decided to charge Rs 3000as a capitation fee which was increased over theyears corresponding with the rise in costs. As ifin anticipation of the present Supreme Courtjudgment he insisted that:1. to get a seat the student seeking admissionshould have passed the qualifying examinationin the first class,2. the fee charged should never be more thanthe actual cost incurred, and3. the institution should meet the stringentnorms set by the Medical Council of India.

Thanks to these strict guidelines, the collegesecured recognition from the Medical Council ofIndia right from the very first batch of studentsand from the General Medical Council, Englandwithin the next five years. Today the KasturbaMedical College, Manipal is regarded as one ofthe best institutions of its kind.

Inspired by the success of the Manipal experi-ment, other private bodies all over the countrybegan to clamour for government sanction toopen professional colleges. Unscrupulousmanagements out to make quick moneygrabbed sanctions and there was soon amushrooming of such institutions. All decentnorms were cast aside and seats were sold tothe highest bidders. No attempt was made toprovide a minimal infrastructure. The backlashwas swift. The capitation fee issue hit theheadlines, there was an uproar in Parliamentand a demand for a blanket ban on privateprofessional colleges.

It is therefore reassuring that the Supreme

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Court has directed that 50% of the seats inprivate professional colleges be made availablefree and that the students admitted against paidseats should pay additional fees for thoseadmitted against the free seats. As long as thecost of running such a college is borne willinglyby affluent parents, the managements will haveno cause for complaint.

With the annual increase in population being18 to 20 million, it will be a long time before thegovernment is able to satisfy the demand forprofessional education through publicly financedcolleges. Its resources should be used to meetthe constitutional obligations to provide freeand compulsory education to all childrenbetween the ages of 6 and 14.

This judgment will put an end to thecommercialization of higher education.

7 March 1993 T. Ramesh U. PaiKasturba Medical College

Manipal

Prejudice Against Reservation

Sir-Dr Mani's philosophy and the conclusionshe draws in his 'Letter from Madras'! are nodifferent from others who, in the name ofscience, perpetuate caste prejudice in the laypress.s-' However, we are disappointed that amedical journal has printed and propagatedpartisan views on sensitive social issues thathave not been substantiated by the availableevidence.

Dr Mani suggests that reservation createsunemployment, and hence ifthis is abolished allbright, 'open' category youths will be admittedto medical courses and become employed later.We request Dr Mani to go through the statis-tics4•5 on the number of positions available forprofessional education and employment in thiscountry and match these with the number ofbright candidates contesting for each seat,excluding the socially and educationally back-ward group. He will find that his hypothesis isindefensible.

Table 1,6 provides evidence that even ifScheduled Castes and Tribes are debarred fromcompeting for the available places, the numberof candidates remaining would be so high thatmost of them would not be selected. SimilarlyTable II,? which shows the representationof Scheduled Castes and Tribes in the class Iservices of the central government and publicsector undertakings, makes it clear that even ifthese positions are shared among others, therewill be a large number who will remainunemployed.

TABLEI. Scheduled Caste/Scheduled Tribecandidates registered for joint entranceexamination for admission to the IndianInstitutes of Technology

Year Total Scheduled ScheduledCastes(%) Tribes(%)

1979-80 51536 3.2 0.71980-81 59621 3.5 0.81981-82 49403 4.2 0.91982-83 54344 4.3 0.8

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TABLE II. Percentage of Scheduled Caste andScheduled Tribe representation in Class Iservices of the central government and publicsector undertakings

Services ScheduledCastes

ScheduledTribes

1971 1991 1971 1991

Central government 2.58 9.09 0.41 2.53Public sector 0.52 5.76 0.17 1.29

Dr Mani has not only tried to denigrate theconsitutional provision of reservation but hasidentified it, through his reductionist analysis,to be the sole cause of frustration of brightunemployed youths. He has convenientlyignored the fact that people belonging to thesocially and educationally backward sections ofsociety might also be frustrated by the injusticethey suffer through institutionalized discrimi-nation." The manifestations of this phenomenonlater are·that, despite there being a large poolof suitable candidates for faculty posts, only avery small number are appointed. For example,Scheduled Castes and Tribes students havebeen trained at the All India Institute of MedicalSciences since 1956 but did not obtain a singlefaculty appointment for the next 28 years."

It has become a fashion, even among scientists,while evaluating the performance of theirsocially and educationally backward country-men, to discuss merit and efficiency in theabstract using some absurd generalizations. 10.11

We could cite the recent securities scam to bethe result of our so-called meritocratic society,at least none of the accused is from the sociallyand educationally backward sections.

1 March 1993 L. R. MurmuShashi Kant

K. R. P. Ranga RaoDepartments of Surgery, Community Medicine

and OrthopaedicsAll India Institute of Medical Sciences

New Delhi

REFERENCES

Mani MK. Letter from Madras. Natl Med I India1992;5:293-4.

2 Kamath MV. Mandalisation and all that. TheHitavada 1990 Sep 5.

3 Palkhivala NA. Mandai perpetuates casteism.The Hindustan Times 1992Nov 30.

4 Degree holders and technical personnel surveycensus 1981. Statistical Tables on Scientific andTechnical Manpower. New Delhi:Division forScientific and Technical Personnel, Council ofScientific and Industrial Research.

5 Facilities to Scheduled Castes and ScheduledTribes in Universities and Colleges. Analysis onthe position of actual admission and employmentof Scheduled Castes and Scheduled Tribes inuniversities and colleges during 1978-79. NewDelhi: University Grants Commission, 1985.

6 Equity, social justice and education. In: Towardsan enlightened and humane society, NPE, 1986-AReview, Part I. New Delhi:Committee for Reviewof National Policy on Education, 1986, 1990:60-72.

7 Welfare and Development of Scheduled Castesand Scheduled Tribes, Eighth Five Year Plan(1992-97), Vol. II. New Delhi:Planning Commis-sion, Government of India, 1992:417-25.

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8 DeVos G. Conflict, dominance and exploitationin the human system of social segregation. In: deAnthony R, Julie K (eds). Conflict in society.London:J. & A. Churchill Ltd., 1966:60-81.

9 Murmu LR. Caste discrimination in India. BM]1992;305:1099.

10 Grover NK. Reservations in medical educationand jobs. ] Indian Med Assoc 1992;90:27-8.

11 Udupa S. Correspondence. I Indian Med Assoc1992;90:192.

The Tragedy of Needless Pain

Sir-Every year approximately one minionnew cases of cancer are diagnosed in India.About 80% of them present in the terminalphases of the disease when their terrible suffer-ing forces them to seek medical help. Cancerpain is the most frightening pain which canbefall any of us. It is highly unlikely that formany years to come, given the current state ofcancer treatment, coupled with the lack ofresources in India, that we will be able toprevent or diagnose cancer early. Therefore,the only realistic current approach would be toprovide relief of symptoms and especially toalleviate pain. Severe pain can be so devastat-ing that people would sooner be dead than haveto live with it.

We all must die. But that I cansave (a person) from days of torturethat is what I feel as my great andever new privilege for pain is amore terrible lord of mankind thandeath himself.

Albert Schweitzer

In the early 1980s, the World HealthOrganization started a world cancer pain reliefadvocacy programme.' A scientifically validatedsimple and inexpensive approach was devisedwhich was easy to apply at the community level.The 'Three-step analgesic ladder' approach wasfield tested in over 2900 patients and provedeffective in relieving pain in at least 75% ofthern.? A judicious use of nonopioid drugs,opioids, and adjunctive medication can relievethe pain effectively. 3 Oral morphine is generallyconsidered to be the drug of choice for moderateto severe pain." However, we seem to stillsubscribe to the old myth that narcotics, soeffective as analgesics, are addictive sub-stances .. The last 25 years of research hasreve~led that morphine, when given to patientsm pam, does not have the side effects previouslydescribed in textbooks' and is rarely associatedwith development of psychological depen-dence." As Twycross has remarked, 'Morphinedoes not exist to be kept on the shelf.' Howeverit is ironic that India, which is one of the largestproducers in the world of the raw material fromwhich medicinal opiates are made,' does

Letters to the editor are considered forpublication subject to editing andabridgement

not make them available to its citizens. Oralmorphine became available in India only in1988. Unfortunately, few have access to it asits supply is limited. Although India has in-corporated cancer pain relief as one of thekey priorities of its national cancer controlprogramme," real progress in making simpleeffective pain medications available has beenpainfully slow.

The World Health Organization has organizedseveral educational programmes in India to dis-seminate knowledge regarding the principles ofpain management. A philanthropic organizationstarted by Gillian Burn, Cancer Relief India,based in London is making wonderful contribu-tions including starting the Joy Burn Pain Clinicin Trichur, Kerala. The states of Kerala andKarnataka have state cancer control programmesincluding measures for pain relief. However,the vast majority of the patients across thecountry continue to suffer needlessly. The qualityof mercy is essential to the practice of medicineand it should not be abandoned. The majormedical institutions and physicians should takethe lead in establishing cancer pain clinics,disseminating knowledge and influencing healthpolicy decisions especially regarding the avail-ability of oral opioids. The art and science ofcontrolling pain are now accepted as legitimatebranches of medicine. Pain control shouldbecome part of the teaching curriculum at everylevel. I hope we can all join together to alleviateso much needless suffering in our country.

I do not want a kingdomI do not want a wife and childrenI do not want rebirthThe only thing I would like is the abatementof the painOf those who are suffering.

Gautama Buddha

25 February 1993 M.M. HaqAnderson Cancer Center

Houston, TexasUSA

REFERENCES

World Health Organization. Cancer pain relief.Geneva:World Health Organization, 1986.

2 Ventafridda V, Tamburini M, Caraceni A, et al. Avalidation study of the WHO method for cancerpain relief. Cancer 1987;59:850-6.

3 Cancer pain relief and palliative care. Report ofWHO Expert Committee. Geneva:World HealthOrganization, 1990:21. .

4 Foley KM. Controversies in cancer pain. Medicalperspectives. Cancer 1989;63:2257--{i5.

5 Houde RW. Misinformation: Side effects and druginteractions. In: Hill CS, Fields WS (eds).Advances in pain research and therapy. Volume II.New York:Raven Press, 145--{i1.

6 Porter J, Jick H. Addiction rare in patients treatedwith narcotics. N Eng/J Med 1980:302:123.

7 Report of International Narcotics Control Boardfor 1989. Demand and supply of opiates for medicaland scientific needs. New York:United Nations,1989.

8 National Cancer Control Plan for India. NewDelhi:Ministry of Health and Welfare, 1984.

9 Burn G. A personal invitation to improve palliativecare in India. Palliative Med 1990;4:257-9.