Medical ethics

As a second kidney racket is unearthed in two months, are hospitals getting away too lightly?

Medical ethics expert Amar Jesani points out that investigations into organ rackets focus on middlemen instead of hospital authorities.

On July 14, an alleged kidney racket was busted in Mumbai's LH Hiranandani Hospital as the police arrested four people, including touts and one transplant recipient. The modus operandi of the Mumbai operation seems similar to a kidney racket unearthed in June at Delhi's Indraprastha Apollo Hospital in which 10 people were arrested. Dr Amar Jesani, editor of the Indian Journal of Medical Ethics, poses questions about investigations into such cases and the responsibility of all institutions that are supposed to regulate transplantation in country as under the Transplantation of Human Organs and Tissues Act, 2011 and Rules 2014.

The recent reports of violations of law related to organ donation are from two large private hospitals. As per the law, in hospitals conducting more than 25 transplants in a year, the hospitals’ authorisation committees should regulate all transplants involving unrelated individuals and donations from foreigners. When the donors are Indian blood relatives of the patient, authorisation should be given by the hospital. In large hospitals transplant co-coordinators may also be appointed.

The hospital requires registration with a nodal agency established for the purpose for organ retrieval as well as transplantation. A cursory reading of the law and rules would show that the hospital has a critical responsibility to ensure that authorisation provided in case of related donors is above board and the authorisation committees function efficiently and independently.

It seems that law enforcement authorities, which found out about the illegality independent of the hospital and concerned authorisation committee, are treating these institutions with kid gloves. Surprisingly, the records of such reported transplants in the hospital and with the authorisation committee are not sealed, and no attempt is made to investigate whether the cases discovered are only a tip of the iceberg.

In order to investigate whether more such cases have happened in the hospital, the police and/or nodal agencies need to review all transplant cases for at least the last one year. The police should also seek medical audits of transplant units and the regulatory audit of the authorisation committees.

Conflict of interest

Commercial hospitals have interest in expanding their business and profits, and so there is always a possibility that many have allowed illegal transplantation for a long time. There indeed is deep-seated conflict of interest between business and their regulation of the law and adhering to ethical practices.

The hospital authorisation committee is chaired by the hospital’s administrator or a doctor appointed by the hospital. Its members include a government representative, two senior doctors of the hospital and two outsiders (non-medical professional, civil society person or others). They are supposed to work independent of the hospital’s business interests and for implementation of law and prevention of exploitation of donors.

So why are only doctors performing organ retrieval and transplantation being questioned, and that also also reluctantly, while hospital administrations and committees not being held accountable? With the hospital nominee as the chair of the committee, there is severe conflict of interest as chair often influences the decision making. Besides, the committee functions in the hospital and is financed by it. Such composition of the committee is a lacuna in the law and is ethically flawed.

Is the functioning of an authorisation committee transparent? Not at all. I have been unable to find, on the website of those hospitals, the names of members of their committees, their background, how many meetings they attended, what kind of decisions they took. There is no information available on the Standard Operating Procedure used by the committees.

In the recent cases in Delhi and Mumbai, neither the hospital that authorised transplantation between living relatives nor the authorisation committee discovered the racket. The crime was brought to light by an informant tipping the police off. This is not new. In case of unethical and illegal clinical trials by the pharma companies in hospitals too, neither hospitals not their ethics committees blew the whistle. Instead, the illegalities were discovered by civil society organisations and the media.

Nodal authority acting like a post office

As per the Transplantation of Human Organs and Tissues Act, there are district, state and national committees that also act as regulatory agencies in addition to hospital administrations and their authorisation committees. Hospitals performing transplantation procedures must be registered with the National Organ Tissue Transplant Organisation.

It is questionable whether this national organisation is ensuring that people appointed to authorisation committees function independently and carry out their responsibilities competently. Is NOTTO checking whether committee members are trained for the tasks they are entrusted to do?

These regulators cannot act just like a post office. Instead they must undertake systematic medical and regulatory audits of institutions registered with them.

If hospitals and committees authorising organ transplantations are not brought into the ambit of investigation, then there seems to be little use of passing a law for regulation of organ transplantation. Unless this changes, there is nothing to prevent such crimes from happening again. Unfortunately, we are looking at the criminals rather than the crime itself, having knee-jerk reaction instead of setting up efficient and competent system for the implementation of law.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

Relying on the power of habits to solve India’s mammoth sanitation problem

Adopting three simple habits can help maximise the benefits of existing sanitation infrastructure.

India’s sanitation problem is well documented – the country was recently declared as having the highest number of people living without basic sanitation facilities. Sanitation encompasses all conditions relating to public health - especially sewage disposal and access to clean drinking water. Due to associated losses in productivity caused by sickness, increased healthcare costs and increased mortality, India recorded a loss of 5.2% of its GDP to poor sanitation in 2015. As tremendous as the economic losses are, the on-ground, human consequences of poor sanitation are grim - about one in 10 deaths, according to the World Bank.

Poor sanitation contributes to about 10% of the world’s disease burden and is linked to even those diseases that may not present any correlation at first. For example, while lack of nutrition is a direct cause of anaemia, poor sanitation can contribute to the problem by causing intestinal diseases which prevent people from absorbing nutrition from their food. In fact, a study found a correlation between improved sanitation and reduced prevalence of anaemia in 14 Indian states. Diarrhoeal diseases, the most well-known consequence of poor sanitation, are the third largest cause of child mortality in India. They are also linked to undernutrition and stunting in children - 38% of Indian children exhibit stunted growth. Improved sanitation can also help reduce prevalence of neglected tropical diseases (NTDs). Though not a cause of high mortality rate, NTDs impair physical and cognitive development, contribute to mother and child illness and death and affect overall productivity. NTDs caused by parasitic worms - such as hookworms, whipworms etc. - infect millions every year and spread through open defecation. Improving toilet access and access to clean drinking water can significantly boost disease control programmes for diarrhoea, NTDs and other correlated conditions.

Unfortunately, with about 732 million people who have no access to toilets, India currently accounts for more than half of the world population that defecates in the open. India also accounts for the largest rural population living without access to clean water. Only 16% of India’s rural population is currently served by piped water.

However, there is cause for optimism. In the three years of Swachh Bharat Abhiyan, the country’s sanitation coverage has risen from 39% to 65% and eight states and Union Territories have been declared open defecation free. But lasting change cannot be ensured by the proliferation of sanitation infrastructure alone. Ensuring the usage of toilets is as important as building them, more so due to the cultural preference for open defecation in rural India.

According to the World Bank, hygiene promotion is essential to realise the potential of infrastructure investments in sanitation. Behavioural intervention is most successful when it targets few behaviours with the most potential for impact. An area of public health where behavioural training has made an impact is WASH - water, sanitation and hygiene - a key issue of UN Sustainable Development Goal 6. Compliance to WASH practices has the potential to reduce illness and death, poverty and improve overall socio-economic development. The UN has even marked observance days for each - World Water Day for water (22 March), World Toilet Day for sanitation (19 November) and Global Handwashing Day for hygiene (15 October).

At its simplest, the benefits of WASH can be availed through three simple habits that safeguard against disease - washing hands before eating, drinking clean water and using a clean toilet. Handwashing and use of toilets are some of the most important behavioural interventions that keep diarrhoeal diseases from spreading, while clean drinking water is essential to prevent water-borne diseases and adverse health effects of toxic contaminants. In India, Hindustan Unilever Limited launched the Swachh Aadat Swachh Bharat initiative, a WASH behaviour change programme, to complement the Swachh Bharat Abhiyan. Through its on-ground behaviour change model, SASB seeks to promote the three basic WASH habits to create long-lasting personal hygiene compliance among the populations it serves.

This touching film made as a part of SASB’s awareness campaign shows how lack of knowledge of basic hygiene practices means children miss out on developmental milestones due to preventable diseases.

Play

SASB created the Swachhata curriculum, a textbook to encourage adoption of personal hygiene among school going children. It makes use of conceptual learning to teach primary school students about cleanliness, germs and clean habits in an engaging manner. Swachh Basti is an extensive urban outreach programme for sensitising urban slum residents about WASH habits through demos, skits and etc. in partnership with key local stakeholders such as doctors, anganwadi workers and support groups. In Ghatkopar, Mumbai, HUL built the first-of-its-kind Suvidha Centre - an urban water, hygiene and sanitation community centre. It provides toilets, handwashing and shower facilities, safe drinking water and state-of-the-art laundry operations at an affordable cost to about 1,500 residents of the area.

HUL’s factory workers also act as Swachhata Doots, or messengers of change who teach the three habits of WASH in their own villages. This mobile-led rural behaviour change communication model also provides a volunteering opportunity to those who are busy but wish to make a difference. A toolkit especially designed for this purpose helps volunteers approach, explain and teach people in their immediate vicinity - their drivers, cooks, domestic helps etc. - about the three simple habits for better hygiene. This helps cast the net of awareness wider as regular interaction is conducive to habit formation. To learn more about their volunteering programme, click here. To learn more about the Swachh Aadat Swachh Bharat initiative, click here.

This article was produced by the Scroll marketing team on behalf of Hindustan Unilever and not by the Scroll editorial team.