A NEED FOR IDENTITY

Medicine cannot be practiced in closed room alone or ethics cannot merely appear on a piece of paper. 

While war crimes, illegal trials, new inventions in biological and medical technologies, debates on the allocation of limited resources, issues concerning eugenics and gene therapy - to name a few - formed the crux of bioethical concerns of First World countries, the same does not hold completely true for the rise of bioethics in India. It cannot be disputed that bioethics has come to India as an import of the West, but bioethics in India cannot be restricted or comprehended within the parameters of research ethics guidelines, ethics committees or even bioethics training courses. Unfortunately little has been done to collate a history from various movements like those in human rights, women's rights, consumers rights, public health initiatives have strongly impacted and informed the bioethics discourse in India. The experiences that have shaped healthcare in India are different from those in the West, and bioethics has to understood through these experiences, these contexts. 

Even as it includes such issues such as euthanasia, in - vitro fertilization, gene therapy, ethics in clinical trial and others, bioethics in India has to equally concern itself with questions of poverty, hunger, disease, government's skewed developmental program's, peoples need and inequalities. 

Medicine cannot be practiced in closed room alone or ethics cannot merely appear on a piece of paper. It cannot be merely regulated by ethics committees or a set of guidelines for clinicians to adhere by. It has to be related to the social, cultural and economic aspects of health and diseases. For bioethics to evolve thus, it first requires to acquire an identity of its own by consolidating the histories that have shaped the field of health in India. These histories have shaped health initiatives and concerns in India. 

This blog is an endevour to create a platform for academic learning and sharing of views on laws, regulations, guidelines and ethical principles governing health and medicine in India. 

Rimali Batra

INTRODUCING MEDICAL ETHICS

Bioethics in India has never captured the popular imagination. Medical issues such as organ transplantation, technologically assisted issues such as organ transplantation, technologically assisted reproduction and euthanasia have now long been around, making noises and evoking debates, and sometimes effecting policy changes. For instance the case of forced narco-analysis on suspected criminals and anti-socials: in response to consistent campaigns against this form test, the Supreme Court of India, in 2010, declared the compulsory use of the test on suspects illegal. That it was up as an agenda by the NHRC (National Human Rights Commission is another matter to consider. But this is one of the many instances when an issue - at the interface of medicine and ethics has been popularly understood as an issue of human rights and not bio-ethics. 

In contract, the West has seen a burgeoning academic interest in bioethics and has witnessed an active involvement of social scientists, especially philosophers - as 'applied science' - a branch of philosophy. But, as Golay rhetorically asks, "Where is the structure [in India] that will enable the engagement between medical practice and the profession of the philosophers which is basically academic?" 

In the absence of academic orientation and the scope to grow as a discipline or a situation promoted forth by philosophical principles, how does bioethics play itself out in India? 

When asked about views of bioethics in India, one of the respondents (a social scientist) said: "Honestly, bioethics is one word is not familiar with, if you want to discuss euthanasia or related subjects, I am there for it. I don't know what bioethics really stands for." [From a new highlight interview of a social scientist who is a member of a Mumbai based Society that defends euthanasia]. His comment on knowing and doing nothing with bioethics goes a long way towards highlighting the non-visibility of bioethics in India. 

While there has been considerable public attention to issue including foetal- sex determination tests, narco-analysis and organ transplant to name a few, they have almost never been discusses as issues in medical ethics. There are no government medical ethics commission like in the US, where they have the presidential commission for study of medical ethics issues. I could suffice it to say that the presence of medical ethics in India as a field of study is fragmentary and in a nascent stage. 

Rimali Batra

SETTING THE STAGE

"Bioethics did not begin with a Big Bang" writes Albert R. Jonsen (1983; 3) delving into origin stories of bioethics . The stage was set against multiple backdrops. A landmark event was the Nuremberg Trial in Germany in 1947, where 23 Nazi physicians and medical administrators were charged with murder, torture and other atrocities committed in the name of medical science. The unethical war crimes captured public imagination. A few years later, the Tuskegee revelations in 1972 in the United States, where 600 poor and uneducated blacks were used as guinea pigs in a clinical trials to test syphilis, exposed by the New York Times, laid the stage for debates on the ethics of medical research across the developing world (Jonsen, 2000). 

1947 onwards, were also marked by a series of biological and medical advances. Innovations like the dialysis machine and assisted reproductive technologies, developments in eugenics, advances in organ transplantation, debates on defining 'death', on abortion and a host of other issues. The engagement with the morality posed by some of these issues, the ethical dilemmas and the legal challenges they stood for, paved the way for a new engagement with medical ethics (Jonsen, 1998; 2000). 

The space provided by the media had a string role to play in taking the issues to the common people who got involved in it as well, and took stands, thereby leading to increased public consciousness. The war crimes, illegal clinical trials, medical advancements that invoked questions of justice, patients autonomy and informed consent, the re-emphasis for doctors to 'first do no harm' - medical beneficence - all together prompted a review of the constituency of the term 'medical ethics'. 

"Answers are needed for personal choices and for policy decisions. These events took place in a cultural, and a social environment that fostered", explains Jonsen (2000;115). And the traditional domain of philosophy, with its already existing theories on ethics, provided material for the disclosure to shape up. This new theatre of bioethics thus had roles and opportunities for doctors, lawyers, sociologists, policy makers, and philosophers and theologists alike. The cast was large and the audience wide. 

The stage was set. 

Rimali Batra