Category Archives: rights

SAVING THE TERRORIST

I have been in Mumbai in the situation it finds itself in at present. I have been in the forefront of a disaster management team (to flatter a rag-tag army of residents, nurses, ward-boys and Superintendents in a Hospital) when the Babri Masjid riots took place in 1992, and, not much later, when the Bombay Stock Exchange and Air India were blown up.

I saw from close quarters how barbaric people can be in the headwinds of the irrationality of collectivism (often religion). I am talking of general wholesale slaughter of any person of a community if he made the mistake of being seen. It cut both ways, and this was doubly unfortunate during the Babri Masjid riots.

I wonder, upon learning that the poor little innocent boy who shot a few people in the railway station (the name changed from Victoria Terminus to the more elegant-sounding and hip CST), wants to live. Poor baby! How can you not want to?
I was thinking if I were the surgeon operating on him (assuming he had major gunshot wounds-which he had not), wouldn’t I have been tempted to let my knife slip near a major vessel and see some major bleeding, thereby causing, if not death, definitely major morbidity?

I would well be tempted, truth to tell. I would have controlled my temptation by telling myself, “He is precious to the country for what secrets he will reveal and your job is to heal, not to kill”. A moment after I think this, I am reminded of the Afzal Mahmoods of the world who got escorted and released by a rat-faced Indian Foreign Minister when Taliban terrorists hijacked an Indian plane to Kandahar.

I am happy I am not treating this dear little kid. I would have actually wrung his neck with my bare hands. Forget the knife (I cannot commit surgical murder-for that I expect to be paid), but with my bare hands, I would have loved to pinch his jugulars and lovingly choke his larynx. A ‘thank you for visiting India’ on behalf of the hundreds of people killed and maimed by him and his friends.

Nevertheless, I wonder: “What is the duty of a doctor to the enemy in times of war?”
I know the textbook answer. I am not sure how real it is. Especially in this kind of war.

IRAN AS THE WORLD’S ROLE MODEL?

According to certain highly educated and qualified people, Iran could be a surprising model for the rest of the world. No, not just in creating nuclear plants and forcing the West to blink, but in their system of allowing organ trade.
An article in Nature India underpins this point along with some interesting ethics issues. If you do not have access to Nature, you could get the same article here. The author of this piece is a familiar name to some of the readers of this blog, as we have discussed some of his earlier publications.
What is the beef of the article?

In India, a huge demand exists for about 200,000 kidneys, with an estimated annual sale of 2000 kidneys. By making organ sale illegal, this market is pushed underground, and organized rackets thrive by working outside the society’s laws and regulations. One of the spin-offs is the phenomenon of organ theft. Such an organ harvest is obviously illegal. Organ theft and organ sale, however, are not the same thing. Every sane person will surely condemn the stealing of a poor man’s kidney, but if such a person volunteers to sell it for money, would it be all bad?

AN IMITATION OF FLATTERY

Someone is taking this blog rather seriously, and copy-pasting stuff in websites.
There is this article on Biointelligence and Morphological Freedom that seems to be lifted right out of the pages of this blog.
Huh.

A NEW FREEDOM FOR THE FUTURE

There is a bomb girl who frequents the same gym I go to. She looks like a movie star, and works ferociously at the various sculpting machines there. She keeps looking back at an imaginary fold of fat at the waist, and keeps whining to the trainer, “I am putting on weight!”
This beauty is spending money, time and effort to beat a non-existent disease: obesity. She is also, potentially, damaging her joints and heart when she pounds the treadmills and pumps the weights. Shouldn’t someone stop her before its too late?
There is another girl I know who wants to trim her inner labia. She seeks a cosmetic gynecologist who does vaginoplasties. And another one who wants a surgery to make her a virgin again, before she gets married a few weeks later. These girls are looking to seek potentially dangerous and complication-prone operations that treat no disease. They are merely expressing some inner wish to change their structure, though there may be nothing fundamentally wrong with them.
I had previously highlighted how the American College of Gynecologists (ACOG) is hotly after the man who has made vaginoplasty a commercial money-spinner. This merely illustrates the fact that there are people in the world, including medical experts, who want to stop procedures that alter one’s physical state. Sex change surgery is another example. There are countries where this is illegal.
The future is fraught with potentially more complex and controversial issues like using genetic engineering and cloning to create a new type of human being that may be peculiarly enhanced. For example, a mother may be able to select a baby who is genetically engineered to see in the dark. Or one who will be free of certain deadly diseases. If you have not read my article on ‘Disruptive Medicine’, this is your lucky day. Check it out.
A Swedish organisation called Eudoxa talks of this morphological freedom, defining it as “an extended right to your own life, including your body.”
Why would a man or woman want to alter his structure for overtly trivial reasons?

We express ourselves through what we are becoming.
Self-development is an intense motivational factor for most humans, and by its
nature this is a very personal and challenging achievement.

Look at tattooing. The way many conservative people see it, it is a kinky and perverse thing to do. It is, however, considered quite cool and contemporary by much of modern society.
It is a personal morphological alteration without specific reasons beyond an individual’s personal choice and freedom of expression.

But wouldn’t genetic modification of children alter society and endanger it? Should we not stop this before it is too late?

Recognizing the right to choose among the many options made available through
morphologic freedom also supports the right not to choose them; the positive and
negative rights are two sides of the same coin.
Purely negative goals like the EU Commission’s directive on children’s right to be
born with unmodified genes will often end up in conflict with positive goals such as
providing children with the best possible medical attention. This right is also
mentioned by the Commission, but is undermined by the negative goal.
One of the many ways this positive goal can be attained is through surgery in the
womb for certain congenital defects. This type of operation changes the body and
the potential person much more than any genetic modification we can bring about.

In other words, apart from the issues of personal freedom and choice, these same disruptive technologies that could change future generations could also save countless lives and improve the lifestyle of the suffering. For example, see the use of intelligent prostheses for amputees that work better than normal limbs.
For more details, check out this link and download a pdf of the statement of Eudoxa.

Whatever be one’s views on this, this issue is a sure one for the future. You haven’t heard anything yet!

A PREMIUM FOR A MAN

Indian business has purchased cricketers from all over the world. Yes, I am talking of the Indian Premiere League auctions at the Hilton in Mumbai. Yesterday was a momentous day in the history of world cricket, and never will cricket be the same again.

It struck me that when the world can appreciate and participate in the auction of live players, what does it find wrong with organ sale or body rentals, aka prostitution?

What is wrong with surrogate motherhood?

Why does the world have different standards of judging these manifestations of the same fundamental principle: that a trade between willing partners is just fine? There cannot be crimes without victims, can there?

NO KIDDING ABOUT KIDNEYS

Finally, someone echoes my thoughts exactly!
An article in The Liberty Institute website says things I would have.
The topic is the kidney scam and the free market. There are several others, even better, on the same subject you can easily find there.
Check it out.

COMPETITIVE, CRAZY CHAUVINISM

The Thackeray clones are fighting to show who is more viciously pro-Marathi and ‘anti-outsider’.

The heir apparent, Udhav Thackeray, has promised to ‘parcel’ outsiders who come to Mumbai for jobs and send them out in cargo planes.

This came shortly after the original agent provocateur, Raj Thackeray, reiterated his views about how hateful it was that North Indians were “forming groups” and were insensitive to Marathi culture. I have no doubt that if he had his way, anyone who disagreed with his views would likely be banished or buried deep under.

So now two parties are competing to be more hateful and insular. Apparently, this is the easiest and most practical way to get popular votes.

Shame on the public for creating these minor monsters! What else can we expect from them, when they voted to power the same people that slaughtered hundreds of Muslims in 1992? Of course, the Muslim parties were responsible in no small measure for the tragedy.

For outsiders who don’t understand this issue, read about the Shiv Sena.

SENT HENCE TO DEATH BY DOCTORS!

In this post, I present a fascinating discussion by some experts on the issues surrounding physicians being involved in judicial execution. This is a topic on which I have been thinking of posting for a while, but I will not offer my views on this now. Just read the transcripts of the interview, which I have taken from the New England Journal of Medicine. If you don’t have the ten minutes needed to read this, I suggest you come back when you do.
A video of the same may be seen here.

THE PROTOCOL

Dr. David Waisel: The three-drug protocol is based on what was considered a normal induction of anesthesia when it was developed. [The first drug is] thiopental, also known as sodium thiopental or pentothal, which is a barbiturate, which is designed to put you to sleep, create amnesia and anesthesia. Second comes pancuronium bromide, which is designed to paralyze the muscles. And the third drug, which is not a drug used in anesthesia, is potassium chloride, which is designed to rapidly stop the heart. The doses used are massive compared to the doses that would be used in a normal anesthetic induction.

Dr. Atul Gawande: You raised, Dr. Truog, [the question of] whether these are the right drugs.

Dr. Robert Truog: We’ve taken a pretty strong stand that paralytic agents have no role in end-of-life care. The concern is that they can mask the behavioral signs that we look to, as to whether or not a patient is comfortable. And we are deeply committed to making sure that patients are comfortable and as free of pain and suffering as possible during the dying process. And since we have medications that do relieve pain, that do sedate perfectly adequately, there’s no need to be introducing paralytic agents into end-of-life care. . . . It’s completely inappropriate to treat those signs and symptoms with a paralytic agent. I think that’s just as true in the execution chamber as in the hospital.

Professor Deborah Denno: According to the state, pancuronium bromide is used in order to enhance the dignity of the inmate who’s dying, because without pancuronium, there might be some jerking or involuntary movements that would disturb some of the witnesses. That I find problematic, and Justice Stevens certainly did.

Dr. Truog: From the point of view of the inmate, the argument seems bizarre. Imagine saying to the inmate, “You have a choice. You can either be assured of a pain-free death, and you may have some twitching and grimacing, or we can expose you to the risk of an excruciating death, but we’ll make sure that you don’t twitch or grimace.” I can’t imagine that an inmate would actually consider that to be a real choice.

ALTERNATIVE APPROACHES

Dr. Truog: The number one alternative that’s been proposed has been a very large dose of a barbiturate. A number of experts have said that 2 or 3 or 5 g of pentothal is absolutely going to be lethal. The fact is that, at least in this country, none of us have any experience with this. And if you look at a country where they do have some experience with it, their findings are pretty concerning.

If we go to Holland, where euthanasia is legal, and look at a study from 2000 of 535 cases of euthanasia, in 69% of those cases, they used a paralytic agent. Now, what do they know that we haven’t figured out yet? I think what they know is that it’s actually very difficult to kill someone with just a big dose of a barbiturate. And, in fact, they report that in 6% of those cases, there were problems with completion. And in I think five of those, the person actually woke up, came back out of coma.

LETHAL INJECTION AND THE EIGHTH AMENDMENT

Dr. Gawande: Professor Denno, [you’ve written that] in turning to this three-drug protocol back in 1977, “The law turned to medicine to rescue the death penalty.” What did you mean by that?

Professor Denno: Lethal injection came about in 1977, a year after the United States Supreme Court decided that there would no longer be a moratorium on the death penalty. And there had been acknowledged problems with electrocution and lethal gas, because of the visual side effects of those methods.

By virtue of coming up with a method of execution that makes an inmate look serene, comfortable, and sleeping during the death process, the death penalty in this country was rescued. The presence of doctors, their involvement, and the association with medicalizing the procedure enhanced its Constitutional acceptability.

Dr. Gawande: What does it mean to be not cruel and not unusual punishment [in compliance with the Eighth Amendment]?

Professor Denno: The Eighth Amendment has never said, nor have the petitioners ever argued, that executions are to be pain-free. The question is whether or not that pain is unnecessary, whether there are alternatives.

Dr. Gawande: Chief Justice Roberts asked, “Do you agree that, if the protocol is properly followed, that there is no risk of pain?”

Dr. Waisel: Define “properly followed.” In other words, the protocols list that this should happen and that should happen. But does that mean if everything happens correctly, if there are no problems with insertion of intravenous catheters, if there’s no problem with mixing up the medications, there’s no problem with delivery of the medications? Then, yes, it would be pain-free.

RISK OF ERRORS

Dr. Truog: I think the issue here is that people go to school for a long time and do years of training in order to be able to do this well. And certainly, everything that I’ve read is that the training for the people that are doing it in lethal injection is nowhere near adequate.

Dr. Gawande: In Kentucky, they have responded to the request by physicians not to have physicians involved. And so it’s staffed entirely by phlebotomists and emergency medical technicians. So how likely is it that errors will occur? By one measure, there have been 40 botched executions out of a little over 900, which suggests a 4-to-5% rate of failure.

Dr. Waisel: We have no idea what the error rate is, because there is no oversight, there is no public reporting. And the information [I] hear worries me. For example, I believe the case was from Missouri, in which they pushed the three drugs, and the inmate didn’t go to sleep. And [they] realized the strap holding the arm was functioning as a tourniquet. So they loosened it up, all the drugs came in at once. Now in that case, I’m highly confident that the inmate experienced a great deal of pain from the potassium chloride. And so I think that your 4-to-5% number is dramatically underestimated.

Dr. Truog: Putting an IV in is not as easy as it may sound. And being certain that it continues to remain in the same place also requires quite a bit of experience, because these catheters can become dislodged, they can go into the tissue, and then they won’t work anymore. Furthermore, we know that many of these inmates, by virtue of their history of drug abuse or obesity or being muscular, can be very difficult to start IVs in.

In a hospital setting, we have a lot of different ways of approaching the situation when we can’t get an IV in. Most commonly, we’ll just put in a central venous line. But that requires a great deal of training. The mixing, the administration of the medications [are] routine in any operating room in this country, but far from routine if you haven’t done it before.

One of the mistakes that I know has occurred happened to me early in my training, when I injected the paralytic agent too quickly after the pentothal, and they precipitated in the tubing. The tubing turned into a piece of concrete. Suddenly, I had no IV. And thank goodness, I was surrounded by very experienced anesthesiologists who stepped in, within moments had another IV. But I know that that has happened in executions, and it could be a disaster.

Dr. Gawande: The petitioners [noted that for] the 3 g of thiopental, no one makes 3 g syringes, so you have to constitute it from small vials of 0.5 g of powder. And several times, whether it’s doctors or non-doctors involved, they’ve simply mixed it up wrong and ended up with much lower doses than they thought.

In Kentucky, the risk of IV infiltration is exacerbated, because they use several feet of tubing, and everybody leaves the room and sits behind a screen where you can’t see the IV sites or monitor how well things are flowing in. And finally, they didn’t have a plan to monitor the depth of anesthesia when you don’t have anybody standing there. And to the extent that there is someone there, they’re not used to being able to assess this.

PHYSICIAN INVOLVEMENT

Dr. Gawande: Now we come to this fundamental question of whether physicians should take charge, to make death less painful. Dr. Truog, what’s your take on [Dr. Waisel’s] question: if you were to be executed, wouldn’t you rather have a capable, specialized physician doing this job?

Dr. Truog: If I think of the kind of a hypothetical where you have an inmate who is about to be executed and knows that this execution may involve excruciating suffering, that inmate requests the involvement of a physician, because he knows that the physician can prevent that suffering from occurring, and if there is a physician who is willing to do that, and we know from surveys that many are, I honestly can’t think of any principle of medical ethics that would say that that is an unethical thing for the physician to do.

Professor Denno: If we’re going to be executing people, I would prefer to have a method of execution where medical expertise would not be necessary. If we’re going to, however, have a method that would be cruel and constitute suffering if we didn’t have doctor involvement, then if there are physicians in the country who are willing to be involved, I would like to think that they would not be chastised or lose their license or be punished by the medical profession for volunteering to take part in an execution, to relieve suffering.

Dr. Truog: There’s been a lot written about whether physicians should participate in torture. And of course physicians shouldn’t participate in torture. But fundamentally, it’s because torture is wrong. And this is [similar] to my views about physician involvement in capital punishment. While I think at one level we can justify it, I think it’s to miss the bigger picture. I really believe that capital punishment is ethically wrong.

Living in the bubble of the United States, it’s easy to lose sight of just how much of an outlier our country is. We stand among a small group of countries that still do capital punishment, [and] I really don’t think we want to be in their company.

REMEDIES

Dr. Gawande: When we come to this question of where can the remedy be found, the directions that seem to be posed are: We involve physicians more and let them treat the prisoner as a patient, or we come up with alternative protocols that don’t involve physicians at all.

Professor Denno: My recommendation has been that there be a panel of experts who would propose a viable method of execution.

Dr. Gawande: It makes me deeply concerned, though, imagining us sitting around a table at a conference, trying to figure out various ways of executing people, and then the prospect of what that becomes, that we figure out that physicians have to be continually actively involved, and we create a specialty of the execution physician.

It may not be possible for the court to say that doctors would be allowed to really treat inmates as patients — control protocol, make judgments about how to make the suffering less or more — and leave them free to have that professional role.

Professor Denno: They’ve been doing that for 30 years. There have been physicians involved in lethal injection since the very first execution in 1982 in this country. Because of secrecy, we’ll never know the full involvement of doctors. But we have many examples of doctors having been involved, who have made these kinds of discretionary judgments about drugs or chemicals and what should be done.

Dr. Gawande: If the court says “We need this to go to an expert panel, with physicians, lawyers, public citizens, to determine a new protocol for execution,” would you participate on that panel? And should other physicians participate on that panel?

Dr. Waisel: It should be wholly permissible for physicians to participate if they wish. I would have to think about it very carefully. A large part would depend on the intellectual freedom involved in the panel, the ability to write a dissenting opinion from what the panel comes up with, and moving away from certain constraints that are put around this that seem not to permit what I would consider to be successful ways of nonphysician involvement.

Dr. Truog: I would not participate on that panel, because I don’t think that capital punishment is ethical. I think other physicians should be free to participate on that panel. And while I wouldn’t want to prejudge how they might come out, I can’t imagine that they are going to be able to develop an evidence base for any other approach that is likely to be successful without the immediate presence of a physician. And then I think we have to grapple with the ethics of that.

NAZIS IN DELHI

Indians, I have long worried, have a strong tendency to be against individual freedom. In the past, many assaults on liberties have taken place, some even enshrined in the Constitution.
Today I learned that Delhi University, including its Student Union, has banned smoking within its campus. Students will not be allowed to smoke in colleges, and on roads or anywhere else. Anyone caught smoking will be considered to be breaking the law, and fined. I suspect the laws also have imprisonment as one of the consequences for repeat offenders, but am not sure about that.

2007-09-03t021508z_01_nootr_rtridsp_2_health-dementia-smokers-dc.jpg

I was taken aback at the virulence on the faces of some of the students campaigning for the ban. It seemed that all of their life’s problems would be over once smoking got banned. There were hardly a couple of feeble voices crying out for individual liberty and freedom.

Of course, I have discussed the issue of non-smokers’ rights in the past, maintaining that only the owner of a private property can declare his area off-limits for smoking. Otherwise, in public places, there have to be designated areas for smokers.

In this case, students are going to learn early in life the importance of cheating, of concealing truth, and bribing as a way of ensuring their self-interest. The police will benefit financially, of course, as will the media, with new stories to cover.

I can only wail at yet another bastion of individual freedom falling to the continuous onslaught of the control freaks, the Nazis of Correctness. Smokers are the new Jews.

The use of force to implement what is construed as the public good characterises every stormtrooper of righteous intent.

(pic credit: http://www.nyu.edu/socialwork/ip/news/archives/2007)

AN IMPATIENT PATIENT?

This blog author has been up to his usual tricks. The ones where he gets paid. And held accountable. No, not for giving ethereal physical pleasures to beautiful women with hour glass figures. The aforementioned never bills for such activity, as it is done with great reciprocal pleasure. Not to speak of the peculiarly perverse view of the world to it. In other words, I am referring to the tender, loving care of surgical patients. Result: no blogging time. No blog surfing time, etcetera.

Allow me some more blogulent digression:
Man is unique in some fundamental ways, compared to the rest of the animal kingdom. The one I am focussing on in this post is the fact that man is one animal whose tail is not much bigger than his head. Except some privileged women.

Well, this post is aimed to correct this human frailty. I will (for reasons of time) posit this very serious issue here, and I expect you, my dearers readers, to wax eloquent in your comments. I will chip in with my views somewhere in between. The beef of the post should reside in the comments!

A colleague in the Western world has a problem:
“Female 99 yrs old, self inflicted stab LUQ, CT scan confirms splenic laceration with extravasation of contrast. Mildly hypotensive – Patient says she ‘DOES NOT’ want an operation, did not want to come to hospital, ‘let me go, I want to die…..’, knows what she has done and where she is, understands that she will die without an operation.” She also takes aspirin, which makes blood thinner, and may increase bleeding. In other words, she has stabbed herself, and is going to bleed to death, unless the doctors operate on her.

Ambulance workers, her GP, and all concerned say she is compos mentis (of sound and reasonable state of mind). Her husband is not available.

What should the doctor do? Plus, what opinions do you have on aging and death?

Let’s hear your tail!