Letters to the Editor
View(s):A fish market more respectable than this motley crowd
Much has been said and written about the shameful behaviour of our politicians in the Parliament. It was shocking that even the usually well behaved gentleman Prime Minister too stooped to shouting slogans in the highest echelon of our nation.
This has been going on for ages. But is anything going to be done about it? Why is it so difficult to impart some common sense into the members of Parliament. They are not only setting a bad example to others in country, eg the children, but now, with everything being televised world over, they are shaming our country‘s image.
Yet, we the citizens too, watch aghast, but do little to stop it. Surely it is not impossible to pass a ruling in Parliament that if anyone behaves in an unbecoming way that he/she should be expelled by the Speaker? According to Wikipedia “The Speaker presides over the House’s debates, determining which members may speak. The Speaker is also responsible for maintaining order during debate, and may punish members who break the rules of the House”.
So Mr. Speaker, why aren’t you doing your duty? Are you afraid to abide by the rules of the country and exert your authority? If you cannot do your duty you must resign and leave the way open for a stronger personality to take over. It is disgusting to watch the Speaker looking on helplessly. And to think that not a single person in that shameful crowd has the guts to speak up to stop the hooliganism. Decent citizens feel the shame in the pit of their stomach that these are the so-called rulers and law-makers of our blessed country. Thumping tables, shouting while another is speaking and getting into fisticuffs – even a fish market is more respectable than this motley crowd.
Dr. Mareena Thaha Reffai Dehiwela
A helping hand to policy holders left in the lurch
Policy-holders receive very prompt service and attention prior to the issue of the insurance policy. However, when a claim arises it is an entirely different story. Many policy holders have difficulties in properly presenting their claims to their insurance companies and obtaining a fair settlement.
Most insurance claims involve technical issues and the claimants encounter serious difficulties in submitting their claims to their insurance companies. As a result, many valid claims are rejected and in some cases legitimate claims are unfairly reduced and the claimants do not receive full compensation. They are then helpless and are unaware how to proceed further and safeguard their interests. In view of the above I commenced an insurance claims consultancy service office in Kandy about two years ago with the assistance of several highly qualified insurance professionals, including Chartered Insurance Practitioners, to fill a large gap in the services provided by insurance companies, brokers and insurance agents to the insuring public. This is to provide a social service to the policy holders who need such assistance, especially those who have been aggrieved and penalised.
My consultants and I provide consultations free of charge. This involves perusing the available claim documents and advising the policy holder on the most appropriate course of action to be followed.
Hilmy Sulaiman Kandy
Medi shocker: Raising some questions at issue
I wish to express my views and medico-legal perspective on the questions raised by the writer in the article titled ‘Medi shocker: Brain dead girl’s organs removed whilst still alive’ (the Sunday Times, February 4). This is in no way a criticism of the facts and opinion expressed by the writer but a clarification of some points raised, to prevent any misunderstanding of the facts by the public.
The Transplantation of Human Tissues Act of Sri Lanka of 1987 deals with many legal aspects of tissue donation. The Criminal Procedure Code also deals with the legal procedures involved in death investigations and autopsy procedures. However, ethical aspects of organ donations have to be considered seriously as unethical conduct could give rise to serious consequences for all; doctors, donors and recipients.
I wish to state that I did not contact any person involved in the medical treatment and organ retrieval or transplantation in this case. My view is based on facts stated in various newspapers and my knowledge and expertise on the subject.
Better understanding of the circumstances could have been achieved if hospital documents were perused and all individuals involved were interviewed. I am not aware whether the previous writer had the chance to obtain all these details but from the contents of the article it appears that he is unaware about some important information and the law governing tissue transplantation.
Question 1: Why was Jeewanthi transferred back?
The NHSL has a special neurotrauma unit with the most modern facilities to treat patients with head injury. This brings out two important questions. Is it ethical to transfer the patient back? Is it the correct management in this particular instance?
A few newspapers have mentioned that a CT or an MRI scan of the brain was done and irreversible severe brain damage was diagnosed by the doctors at the NHSL. It is very likely that such patients with severe brain injuries need ventilation until they recover or succumb to injuries. Though the NHSL has many Intensive Care Units (ICUs) all ventilators are almost always occupied by patients needing the life support system. The turnover of patients with serious brain injury is very high at NHSL as it functions as a tertiary care hospital and it receives patients from every corner of the island. In some instances, it is very difficult or even impossible to find a vacant ventilator in any of the ICUs at NHSL. So it is logical and ethical to transfer the patient to a unit where a ventilator is available. According to one Sinhala newspaper, the patient had been on ventilator support at the Homagama Base Hospital which means that a ventilator was available there. So isn’t it prudent to transfer the patient there for ventilator support?
The writer says that “if there was hope to revive her; the hope lay nowhere else but in its (NHSL) wards”. Is it logical and ethical to keep a patient who needs ventilator support in a general ward? If this was done the patient would have died hours earlier. It would also amount to medical negligence due to the fact that necessary action was not being taken to treat her properly. In my opinion, the doctors have done what is logical and ethical by transferring the patient back to Homagama where ventilator support was available.
Question 2: Did lack of medical attention during the re-transfer result in irreversible brain damage?
This is a difficult question to answer with a certainty. The condition of a patient with severe brain injury can deteriorate at anytime, irrespective of whether medical attention is given or not. However, accepted procedure in transferring a patient is that a nursing officer or a trained para-medical person accompanies the patient. Occasionally, doctors also accompany patients but this is subject to their availability at that moment. On the other hand, the same potential threat would have been there during the initial transfer of the patient to NHSL. But no one will ever question the reason for her transfer to NHSL.
CT and MRI scanning facilities are not available at Homagama and there is no option but to transfer the patient to NHSL for further investigations. The actions taken have to be considered together with options available in the best interests of the patient. Isn’t it logical and ethical to transfer back the patient to Homagama for ventilator support rather than keeping her in a general ward without a ventilator and allowing her to die sooner?
Question 3: The writer raises the question why the patient was kept on a ventilator without being disconnected. The reason is simple. Once the decision to harvest organs is taken, ventilator support should be continued until such harvesting to prevent putrefaction of organs. This is a genuine technical issue.
Question 4: The writer correctly says that there is a thin line dividing the sublime from the ridiculous and the genius from the lunatic. The thin line here means that it is difficult to differentiate between the two conditions. However, it is incorrect to say that there is a thin line between brain death and a coma. In medical practice, the difference of the two is very obvious. Probably what the writer refers to is the usual way of confirming death in a normal ward. This is not the procedure adopted in diagnosing brain death in a patient on ventilator support.
The accepted procedure in diagnosing brain death is that it is done by two consultants separately on two occasions – excluding the doctors involved in the tissue transplantation team. Many brain functions are assessed and the tests are repeated after some time. A basic vital function is the presence of spontaneous breathing as in the absence of spontaneous respiration an individual will not be able to survive as the oxygenation process of blood won’t occur and cells would die soon due to lack of oxygen.
Question 5: The writer asks whether the doctors at Homagama can declare a patient brain dead when the heart goes on? In medical terminology there is ‘beating heart cadaver’. It means that the patient is dead but the heart is beating. This can happen but not under normal circumstances. The heart has an innate capability of beating on its own. This innate capability of beating on its own lets the heart beat for a very short time after brain death is confirmed. Could it go on for a considerable period? No. Once the brain is dead the capability of having spontaneous respiration is lost and the oxygenation of blood doesn’t happen. This automatically stops the provision of oxygenated blood to body tissues including the heart making them incapable of remaining alive.
What actually happens in a ventilated patient is that the machines act as an artificial lung and keep the oxygenation process going on maintaining circulation. This means that it is the machine that keeps the heart going on. Therefore, technically and medically a brain dead patient cannot be considered as being alive. The patient is dead and a dead patient doesn’t have sensations as far as medicine is concerned.
Question 6 : Already discussed under Question 3.
Question 7: The writer has questioned the validity of the consent obtained. It seems that the writer is unaware about the law pertaining to tissue transplantation which deals with different types of consent.
In this case, the husband is dead and her child is a minor. Therefore, the father of the deceased has the legal right to consent.
The writer says that no one can give consent to ’medical ghouls to thieve the assets of their beloved….’. I cannot understand why the writer considers this a theft when it is legally permitted and done to save the lives of many others awaiting organ donations.
Question 8: I have already answered the issues raised on this question.
Question 9: The writer theorizes about what happened after the diagnosis of brain death. I am unaware about what exactly happened or how the message was communicated to the relatives but I also don’t find anything wrong in what the writer has suggested here. Is there a better way of telling them the outcome and getting consent for organ retrieval?
What doctors have done in this case is not to play the role of God but it is a simple act of humanity being within the law, ethics and accepted medical practice.
The public media should carry the true picture about important events and issues. It is true that legislation and code of ethics do not always ensure rightful acts by all individuals. If someone does something wrong it is an individual issue not a fault of the accepted procedure and system. Laws can take necessary action if someone does anything illegal.
Dr. N.D.N.A. Mendis,
Senior Lecturer and Specialist in Forensic Medicine,
Faculty of Medicine, University of Colombo