Thursday, September 11, 2008

Bioethics and brains in India

India is a land of contrasts. There is its well-known and longstanding cultural, religious and linguistic diversity. On top of that, India has emerged as one of the world's most rapidly industrializing societies, an important outsourcing location for multinational corporations -- including pharmaceutical companies and their clinical trials -- and a popular destination for medical tourism. At the same time, a quarter of the nation's population (282 millon people) still earns less than $0.40 per day.

The isolated enclaves of 'first-world' health care within India are also giving rise to some difficult bioethical challenges. The Times of India reports that in government hospitals in Chennai, no brain deaths are being reported, and hence no organ transplants of brain dead patients are taking place. Brain death is the medical precondition for organ transplant under India's Tranplantation of Human Organs Act (1994). So why are brain deaths not being reported? The article gives two revealing reasons. First, establishment of brain death requires performing an EEG on the patient, and the technicians who perform this do not work nights. But what about those patients that seemingly lose brain stem function during the day? This is apparently where the other reason comes into play: local doctors do not see brain dead patients, even when an EEG establishes the absence of function, as really dead. Even when the function of vital organs is dependent on machines, the sheer fact that the heart is still beating and the lungs are still pumping spells -- for local physicians -- the continuing presence of life. The head of one of the hospitals, in order to encourage doctors to 'buy in' to the idea of brain death, plans to hold a campaign asking doctors to pledge their own organs in the event they should become brain dead. Best of luck with that: they would probably rather die -- in the old fashioned, cessation of heart and lungs sense.

Another recent controversy in India involves the brains of the living, in this case the brains of criminal suspects. Aditi Sharma was accused of poisoning her former fiance with arsenic while they were eating at a McDonalds in the city of Pune (A fascinating story in itself, no doubt.). She denied the accusation of murder, but agreed to participate in a Brain Electrical Oscillations Signature test (BEOS), developed by neuroscientist Champadi Raman Mukundan. When details of the crime were read out to her, sections of Ms. Sharma's brain lit up. The prosecutor used this data to successfully argue that Ms. Sharma had "experiential knowledge" of the murder, i.e. that while she denied it with her words, her brain activity showed that she was the murderer.

Could this new biotechnology play a role analogous to DNA testing as an independent way to establish or disprove criminal guilt? Scientists are skeptical, but law-enforcement and counter-terrorist agencies are interested. In theory, such technology could do away with the practice of torture aggressive interrogation, and the pleasure of the sadists who conduct it. In practice, unless the BEOS is quasi-infallible, it will be a new faciliator of wrongful conviction.

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Blogger Jim Sabin said...

Hi Stuart -

Thank you for this very intereseting post. I'm not sure what to make of the two brain examples - too little belief in the meaning of assessments of brain function (re brain death) and too much belief in assessments of brain function (re murder conviction), but as you say, India is a culture of dramatic contrasts.

I hope you'll write in the future about the contrast between upscale developed world medicine at Apollo Hospitals, Wockhardt Hospitals, and the like, and the $0.40/day sector. A young Indian friend - a very able physician - told me that he is the only member of his medical school class of comparable ability still in India. Do you think the top-of-the-line hospitals will keep able physicians in the country and create trickle down improvement of the public sector, or will it simply suck more blood away from public care?



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