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.

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“My body instantly craves chai and samosa”

German expats talk about adapting to India, and the surprising similarities between the two cultures.

The cultural similarities between Germany and India are well known, especially with regards to the language. Linguists believe that Sanskrit and German share the same Indo-Germanic heritage of languages. A quick comparison indeed holds up theory - ratha in Sanskrit (chariot) is rad in German, aksha (axle) in Sanskrit is achse in German and so on. Germans have long held a fascination for Indology and Sanskrit. While Max Müller is still admired for his translation of ancient Indian scriptures, other German intellectuals such as Goethe, Herder and Schlegel were deeply influenced by Kalidasa. His poetry is said to have informed Goethe’s plays, and inspired Schlegel to eventually introduce formal Indology in Germany. Beyond the arts and academia, Indian influences even found their way into German fast food! Indians would recognise the famous German curry powder as a modification of the Indian masala mix. It’s most popular application is the currywurst - fried sausage covered in curried ketchup.

It is no wonder then that German travellers in India find a quite a lot in common between the two cultures, even today. Some, especially those who’ve settled here, even confess to Indian culture growing on them with time. Isabelle, like most travellers, first came to India to explore the country’s rich heritage. She returned the following year as an exchange student, and a couple of years later found herself working for an Indian consultancy firm. When asked what prompted her to stay on, Isabelle said, “I love the market dynamics here, working here is so much fun. Anywhere else would seem boring compared to India.” Having cofounded a company, she eventually realised her entrepreneurial dream here and now resides in Goa with her husband.

Isabelle says there are several aspects of life in India that remind her of home. “How we interact with our everyday life is similar in both Germany and India. Separate house slippers to wear at home, the celebration of food and festivals, the importance of friendship…” She feels Germany and India share the same spirit especially in terms of festivities. “We love food and we love celebrating food. There is an entire countdown to Christmas. Every day there is some dinner or get-together,” much like how Indians excitedly countdown to Navratri or Diwali. Franziska, who was born in India to German parents, adds that both the countries exhibit the same kind of passion for their favourite sport. “In India, they support cricket like anything while in Germany it would be football.”

Having lived in India for almost a decade, Isabelle has also noticed some broad similarities in the way children are brought up in the two countries. “We have a saying in South Germany ‘Schaffe Schaffe Hausle baue’ that loosely translates to ‘work, work, work and build a house’. I found that parents here have a similar outlook…to teach their children to work hard. They feel that they’ve fulfilled their duty only once the children have moved out or gotten married. Also, my mother never let me leave the house without a big breakfast. It’s the same here.” The importance given to the care of the family is one similarity that came up again and again in conversations with all German expats.

While most people wouldn’t draw parallels between German and Indian discipline (or lack thereof), Germans married to Indians have found a way to bridge the gap. Take for example, Ilka, who thinks that the famed differences of discipline between the two cultures actually works to her marital advantage. She sees the difference as Germans being highly planning-oriented; while Indians are more flexible in their approach. Ilka and her husband balance each other out in several ways. She says, like most Germans, she too tends to get stressed when her plans don’t work out, but her husband calms her down.

Consequently, Ilka feels India is “so full of life. The social life here is more happening; people smile at you, bond over food and are much more relaxed.” Isabelle, too, can attest to Indians’ friendliness. When asked about an Indian characteristic that makes her feel most at home, she quickly answers “humour.” “Whether it’s a taxi driver or someone I’m meeting professionally, I’ve learnt that it’s easy to lighten the mood here by just cracking a few jokes. Indians love to laugh,” she adds.

Indeed, these Germans-who-never-left as just diehard Indophiles are more Indian than you’d guess at first, having even developed some classic Indian skills with time. Ilka assures us that her husband can’t bargain as well as she does, and that she can even drape a saree on her own.

Isabelle, meanwhile, feels some amount of Indianness has seeped into her because “whenever its raining, my body instantly craves chai and samosa”.

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This article was produced by the Scroll marketing team on behalf of Lufthansa as part of their More Indian Than You Think initiative and not by the Scroll editorial team.