Paradigm shift in medical ethics

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Dr KK Aggarwal

There has been a paradigm shift in the thinking of the public. There has been a corresponding paradigm shift in the dynamics of doctor-patient relationship; from paternalism to patient-centric. Today, patients want to be equal partners in decisions about their treatment with the doctor acting as a guide and facilitate decision making. Patient autonomy is also now at the forefront of the principles of medical ethics, along with non-maleficence (do no harm) and beneficence (do good).

From Vedic point of view, the public perception has rapidly shown a shift from Karma Marg to Bhakti Marg and to Gyan Marg. In Karma Marg, people surrender to the doctor-patient relationship. In the phase of Bhakti Marg, they show faith and Gyan Marg, is marked by suspicion and hunger to know why.

There are four types of patients today based on four levels of awareness i.e. their ability to retain knowledge or information that is given to them by the doctor pertaining to their disease. These four levels of awareness are “ignorant, informed, empowered and enlightened”.

• Ignorant patients do not participate in decision making and depend on the doctor to make their decisions, with no questions asked.

• Informed patients have questions for the doctor, but only few. These patients then usually agree to the line of treatment adopted by the doctor.

• Empowered patients have many more questions, they cross check facts and are an equal partner in decision making regarding their treatment.

• Enlightened patients seek the opinions of many are only then convinced about the proposed line of treatment. Convincing these patients involves several counseling sessions.

There can also be three types of doctors.

• Doctors who expect patients to accept what they say.

• Doctors give choices to patients and ask them to choose.

• Doctors who give choices to their patients, but help them to choose the best option.

Miscommunication is at the root of many doctor-patient disputes. This occurs when the level of awareness of doctor and the patient do not match.

There are also four types of students as per Rabbi Dovid Rosenfeld according to the ability to retain the knowledge taught to them: Sponge, a funnel, a strainer and a sifter.

• The sponge retains everything, but is unable to distinguish between correct and incorrect points. He lacks Viveka, the power of discrimination. The funnel is the one for whom information goes in one ear and out the other. With no focus, his hearing and the mind are in different directions.

• The strainer discards the wine (significant material) and retains the lees (incorrect or insignificant points). He remembers all sorts of trivial or useless details of the material he studied.

• The sieve retains the fine flour (significant material) and discards the dust (inconsequential details). He understands the lecture by its main points and remembers them in the form of sutras.

The principle of “suno – samjho – jano – karo” exemplifies this. This is also the gist of Vedic science and has also been clearly defined in Bhagavad Gita by Lord Krishna. We should hear, listen, understand and convert it into wisdom. Hearing means that you hear anything but listening means that you should learn its meaning. Understanding means you should understand its value in your context and wisdom means you should practice it, re-practice it and learn intricacies of its implications. Once knowledge has been converted into wisdom it is of no use unless it is made use of in day-to-day practice.

Similarly, there has also been a paradigm shift in the accountability for doctors. There was an era when self-regulation in the form of an oath was sufficient (Hippocratic and Medical Council of India [MCI] Oath). As this was considered insufficient, the Code of Medical Ethics Regulations came into force from 2002, which was rapidly followed by Consumer Protection Act (CPA), civil liabilities and now criminalization of medical practice including 304 A.

The Code of Ethics Regulations, 2002 is not simply an Ethics code; it is also about conduct and etiquettes. Unfortunately, ethics, conduct and etiquettes are not taught in the medical curriculum. It is also important to differentiate between unethical acts and professional deficiency.

Therefore, today one is not only required to be scientifically correct, but also morally, ethically and legally correct.

Individual ethics (dharma) or code of conduct (ethics in society) change according to society. Dharma (to hold people together) changes as per the collective consciousness of the people. As people are empowered, ethics will also change.

Disclaimer: The views expressed in this write up are entirely my own.

Iodine essential for growth and brain development in infants

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Women planning to conceive should get adequate sources of iodine in their diet

New Delhi, 20 October 2017: As per a study, about 42 million Indians have abnormal thyroid hormone levels. It also indicated that India accounts for 21% of the global population with thyroid disorders. The prevalence of thyroid disorders was more in women than men with about 26% women diagnosed with abnormal TSH levels compared to 24% men. Thyroid disorders are a major outcome of iodine deficiency.

On World Iodine Deficiency Day, there is a need to create awareness on the fact that Iodine is an essential micronutrient required for human growth and development. The average daily requirement of iodine for a normal person is 150 micrograms a day. The requirement of iodine is more in pregnant women than normal women, because the effects of iodine deficiency are most severe in pregnant women and for their babies.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, “Iodine is stored in the thyroid gland and is important for the production of thyroid hormones thyroxine (T3) and triiodothyronine (T4). Thyroid hormones are needed for the proper development of cells. They have a major role in increasing the metabolic rate of the body and in metabolism of protein. They regulate the growth of long bones and are essential for brain development. Thyroid hormones are also closely linked to fat and carbohydrate metabolism in cells. Iodine deficiency can cause goitre (enlargement of thyroid), hypothyroidism and mental retardation in infants and children whose mother was iodine deficient during pregnancy.”

When the thyroid produces too much hormone it causes hyperthyroidism and when it produces less than what is needed, the condition is called hypothyroidism. Other common disorders of the thyroid are Hashimoto’s disease, Graves’ disease, goiter, and thyroid nodules.

Adding further, Dr Aggarwal, said, “Women planning to conceive should make sure that they get adequate amounts of iodine in their diet to build up good stores before getting pregnant. Pregnancy and lactation increase the demand for iodine to make adequate thyroid hormones, which play a crucial role in the baby’s brain development. Eating a healthy and varied diet is essential to meet one’s iodine needs.”

The following are some good sources of iodine.
• Cheese Most dairy products are iodine enriched. Two varieties of cheese that are rich in this mineral include Cheddar and Mozzarella.
• Seaweed Iodine is found in both this and seafood. One of the richest sources is a seaweed called kelp.
• Eggs Eggyolk is one of the safest and simplest sources of iodine.
• Milk Studies indicate that every 250ml of milk has about 150 micrograms of iodine.
• Yoghurt A single cup of yoghurt can meet half of the daily iodine requirement giving close to 70 micrograms of iodine. It is also good for the stomach and rich in calcium and protein.
• Apart from the above food items, some others that are good sources of iodine include fruits like bananas, strawberries; vegetables such as green leafy vegetables, onions, and sweet potatoes; and grains, nuts and legumes like peanuts, barley, etc.