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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Some of the worst decisions made in history

From the boardroom to the battlefield, bad decisions have been a recipe for disaster

On New Year’s Day, 1962, Dick Rowe, the official talent scout for Decca Records, went to office, little realising that this was to become one of the most notorious days in music history. He and producer Mike Smith had to audition bands and decide if any were good enough to be signed on to the record label. At 11:00 am, either Rowe or Smith, history is not sure who, listened a group of 4 boys who had driven for over 10 hours through a snowstorm from Liverpool, play 15 songs. After a long day spent listening to other bands, the Rowe-Smith duo signed on a local group that would be more cost effective. The band they rejected went on to become one of the greatest acts in musical history – The Beatles. However, in 1962, they were allegedly dismissed with the statement “Guitar groups are on the way out”.

Source: Wikimedia Commons
Source: Wikimedia Commons

Decca’s decision is a classic example of deciding based on biases and poor information. History is full of examples of poor decisions that have had far reaching and often disastrous consequences.

In the world of business, where decisions are usually made after much analysis, bad decisions have wiped out successful giants. Take the example of Kodak – a company that made a devastating wrong decision despite overwhelming evidence to the contrary. Everyone knows that Kodak couldn’t survive as digital photography replaced film. What is so ironic that Alanis Morissette could have sung about it, is that the digital camera was first invented by an engineer at Kodak as early as 1975. In 1981, an extensive study commissioned by Kodak showed that digital was likely to replace Kodak’s film camera business in about 10 years. Astonishingly, Kodak did not use this time to capitalise on their invention of digital cameras – rather they focused on making their film cameras even better. In 1996, they released a combined camera – the Advantix, which let users preview their shots digitally to decide which ones to print. Quite understandably, no one wanted to spend on printing when they could view, store and share photos digitally. The Advantix failed, but the company’s unwillingness to shift focus to digital technology continued. Kodak went from a 90% market share in US camera sales in 1976 to less than 10% in 2012, when it filed for bankruptcy. It sold off many of its biggest businesses and patents and is now a shell of its former self.

Source: Wikimedia Commons
Source: Wikimedia Commons

Few military blunders are as monumental as Napoleon’s decision to invade Russia. The military genius had conquered most of modern day Europe. However, Britain remained out of his grasp and so, he imposed a trade blockade against the island nation. But the Russia’s Czar Alexander I refused to comply due to its effect on Russian trade. To teach the Russians a lesson, Napolean assembled his Grand Armée – one of the largest forces to ever march on war. Estimates put it between 450,000 to 680,000 soldiers. Napoleon had been so successful because his army could live off the land i.e. forage and scavenge extensively to survive. This was successful in agriculture-rich and densely populated central Europe. The vast, barren lands of Russia were a different story altogether. The Russian army kept retreating further and further inland burning crops, cities and other resources in their wake to keep these from falling into French hands. A game of cat and mouse ensued with the French losing soldiers to disease, starvation and exhaustion. The first standoff between armies was the bloody Battle of Borodino which resulted in almost 70,000 casualties. Seven days later Napoleon marched into a Moscow that was a mere shell, burned and stripped of any supplies. No Russian delegation came to formally surrender. Faced with no provisions, diminished troops and a Russian force that refused to play by the rules, Napolean began the long retreat, back to France. His miseries hadn’t ended - his troops were attacked by fresh Russian forces and had to deal with the onset of an early winter. According to some, only 22,000 French troops made it back to France after the disastrous campaign.

Source: Wikimedia Commons
Source: Wikimedia Commons

When it comes to sports, few long time Indian cricket fans can remember the AustralAsia Cup final of 1986 without wincing. The stakes were extremely high – Pakistan had never won a major cricket tournament, the atmosphere at the Sharjah stadium was electric, the India-Pakistan rivalry at its height. Pakistan had one wicket in hand, with four runs required off one ball. And then the unthinkable happened – Chetan Sharma decided to bowl a Yorker. This is an extremely difficult ball to bowl, many of the best bowlers shy away from it especially in high pressure situations. A badly timed Yorker can morph into a full toss ball that can be easily played by the batsman. For Sharma who was then just 18 years old, this was an ambitious plan that went wrong. The ball emerged as a low full toss which Miandad smashed for a six, taking Pakistan to victory. Almost 30 years later, this ball is still the first thing Chetan Sharma is asked about when anyone meets him.

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