Violence Against Doctors: Lethal Blow

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Reproduced from: http://www.indialegallive.com/viewpoint/violence-against-doctors-lethal-blow-70584, published August 11, 2019

In a positive development, a draft bill has proposed that violence against Doctors be made a criminal offence, resulting in hefty fines and a jail term according to the type of assault

A doctor’s profession is one of the most sacred. His basic role is to relieve the sufferings and pain of an individual. In most other professions, people charge for providing services during an emergency, but not doctors.

Under Article 21 of the Constitution, health is a fundamental right and under Article 47 of the Directive Principles of State Policy, both primary and urgent care are to be provided free by the State. Currently, most states are not able to provide effective emergency medical care to their residents and the load is transferred to the private sector which charges exorbitantly. Also, many government hospitals do not take patients on ventilators, deliveries booked outside for C-section, acute terminal care, new-borns delivered outside with sepsis, etc. The costs of acute care in a good private hospital may vary from Rs 50,000 to Rs 1 lakh a day, which is beyond the capacity of most people. Insurance companies also do not cover much of the cost. The result is instances of assault and violence against doctors.

Now the time has come when not only the medical fraternity, but the public at large should be concerned about the rising incidents of violence against health personnel. But in a positive development, hefty punishments are proposed to be imposed on those who indulge in such acts. If doctors and other healthcare staff are under constant threat, they will not be able to treat patients. If nothing is done immediately to curb this, a time will come when there will be very few doctors. As of now, even the brightest students prefer non-clinical practice. Amulya R, a gold medallist MBBS student from Bidar Institute of Medical Sciences, Bengaluru, said in an interview on March 18, 2017: “It really upsets me the way doctors are assaulted these days. Looking at these incidents, I would prefer a non-clinical subject like pathology for my post-graduation.”

Some incidents of assault have even caused deaths of doctors. In many cases, grievous injuries have been inflicted and public property damaged. In a case in 2017, a senior orthopaedic resident, Rohan Mahamumkar, lost vision in his left eye after being assaulted by the relatives of a patient who had been brought in with a head injury at Government Medical College in Dhule. Mahamumkar had asked the patient’s family to take him to another centre as no neurosurgeon was available at that time. This infuriated them enough to attack him.

There are many reasons for frequent incidents of violence and assault on doctors: Shortage of facilities and medical professionals in government/public hospitals; poor doctor-patient ratio; poor arrangement of safety and security of healthcare professionals in government hospitals and lack of efficient management and administration.

In the last few years, state governments/Union Territories (UTs) have been deliberating on the issue of violence against medical personnel. Till date, 18 states/UTs have brought in legislation on this subject, including Delhi, during the period 2007-13. In a majority of them, the offence of violence and assault has been made cognisable and non-bailable with imprisonment up to three years and a fine up to Rs 50,000.

Despite this, the biggest problem is lack of awareness among police authorities and inaction on their part in registering a criminal case against accused persons. Violence against doctors and any person is also a punishable offence under the Indian Penal Code (IPC). Yet, there is a need for a central law for the protection of doctors. The medical fraternity has been demanding this for quite some time.

After much persuasion, in 2015, under pressure from the IMA, the central government constituted a committee to examine the issue of violence against doctors. The report of the committee was finalised on March 23, 2017, wherein it recommended the following measures:

  • The ministry of health shall suggest to all states which do not have specific legislation to protect doctors/health professionals to consider enacting one.
  • The ministry shall write to all states to strictly enforce the provisions of the special legislation wherever it exists and/or enforce the IPC/CrPC provisions with vigour.
  • The ministry shall explore the possibility of initiating the process to bring a central act on the issue in line with those in vogue in other states.

However, the central government did nothing on these recommendations, eventually leading to increased assault cases and a nationwide strike by doctors. After one such incident of assault in West Bengal, the centre constituted an inter-ministerial committee which promised to enact a central act soon.

The draft Bill for the protection of doctors was presented to a 10-member committee constituted by the health ministry in July to see the feasibility of it being made into a central law and to make it a criminal offence under the IPC and the CrPC. The committee decided that such a law was needed, and an eight-member subcommittee was created to draft the Bill. As per the draft Bill, assaulting and “grievously injuring” doctors on duty can result in 10-year imprisonment or fine up to Rs 10 lakh.

The most important aspect of the draft Bill is the gradation system, which will consider the type of assault and prescribe the punishment accordingly. For example, the minimum punishment would be six months’ imprisonment and/or Rs 50,000 fine for a simple injury. The maximum punishment would be five years’ imprisonment and/or Rs 5 lakh fine. For a serious injury due to which a doctor has to miss work for 20 days, the punishment would be imprisonment between two to 10 years and fine between Rs 2 lakh and Rs 10 lakh.

The Bill will make assault on doctors a cognisable and non-bailable offence, which means that an accused person can be arrested without a warrant and will need to approach a magistrate or court for bail. The Bill does not address injuries that might lead to death as that is already covered under the IPC/CrPC. The draft Bill also does not make provisions for an institutional FIR, which was a request raised by the Federation of Resident Doctors’ Association.

However, enacting a central law is not the only solution. Other solutions which are vital are:

  • State laws dealing with violence against doctors should be advertised.
  • Workshops, seminars, etc, should be organised to educate the public and doctors about the penal provisions.
  • Patients’ rights should be displayed in every hospital and clinic.
  • Patients should be educated about the significance of informed consent, triage in emergency and sensitised that error of judgement does not automatically mean negligence.
  • There should be a grievance redressal mechanism for both patients and doctors in every healthcare establishment.
  • Right communication is the key to a strong doctor-patient relationship.
  • The charges on patients should be clear and transparent.
  • There should be rational treatment, rational prescription and transparency in investigations and treatment.
  • Hospitals should identify high-risk areas and install audio-based CCTV cameras there.
  • Bodies of deceased patients cannot be held hostage for financial disputes.
  • Hospitals should make adequate security arrangements for the protection of doctors and nurses, especially in the night.
  • CPR and first-aid should be made available everywhere.
  • There must be a provision for briefing the legal heirs.
  • Nurses and paramedical staff should be trained in soft communication.

The media and police too have an important role to play in preventing violence against doctors and hospital staff. No news article should be published without proper verification. Police officers should be sensitised about violence against doctors and the laws and guidelines laid down by the Supreme Court.

It is a sad reflection of our society that the very people who look after others are now being made victims for no fault of theirs.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

With NMC taking over it may be time to revise MCI Code of Ethics (Part 3)

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The MCI Code of Ethics Regulations requires a Declaration (Appendix 1) to be signed and submitted at the time of registration.

  1. DECLARATION

1)    I solemnly pledge myself to consecrate my life to service of humanity.

2)    Even under threat, I will not use my medical knowledge contrary to the laws of Humanity.

3)    I will maintain the utmost respect for human life from the time of conception.

4)    I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.

5)    I will practice my profession with conscience and dignity.

6)    The health of my patient will be my first consideration.

7)    I will respect the secrets which are confined in me.

8)    I will give to my teachers the respect and gratitude which is their due.

9)    I will maintain by all means in my power, the honour and noble traditions of medical profession.

10)  I will treat my colleagues with all respect and dignity.

11)  I shall abide by the code of medical ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002. I make these promises solemnly, freely and upon my honour.

Here is what the American Medical Association (AMA) has to say about professional responsibility and the Declaration.

Appendix D Declaration of Professional Responsibility

Preamble:

Never in the history of human civilization has the well-being of each individual been so inextricably linked to that of every other. Plagues and pandemics respect no national borders in a world of global commerce and travel. Wars and acts of terrorism enlist innocents as combatants and mark civilians as targets. Advances in medical science and genetics, while promising great good, may also be harnessed as agents of evil. The unprecedented scope and immediacy of these universal challenges demand concerted action and response by all. As physicians, we are bound in our response by a common heritage of caring for the sick and the suffering. Through the centuries, individual physicians have fulfilled this obligation by applying their skills and knowledge competently, selflessly, and at times heroically. Today, our profession must reaffirm its historical commitment to combat natural and man-made assaults on the health and well-being of humankind. Only by acting together across geographic and ideological divides can we overcome such powerful threats. Humanity is our patient.

Declaration

We, the members of the world community of physicians, solemnly commit ourselves to:

  1. Respect human life and the dignity of every individual.
  2. Refrain from supporting or committing crimes against humanity and condemn all such acts.
  3. Treat the sick and injured with competence and compassion and without prejudice.
  4. Apply our knowledge and skills when needed, though doing so may put us at risk.
  5. Protect the privacy and confidentiality of those for whom we care and breach that confidence only when keeping it would seriously threaten their health and safety or that of others.
  6. Work freely with colleagues to discover, develop, and promote advances in medicine and public health that ameliorate suffering and contribute to human well-being.
  7. Educate the public polity about present and future threats to the health of humanity.
  8. Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.
  9. Teach and mentor those who follow us for they are the future of our caring profession.

We make these promises solemnly, freely, and upon our personal and professional honor.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Some definitions related to tobacco and other common addictions

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Here is a list of definitions of various terms related to tobacco and other common addictions as to what do they actually mean. This will help to understand the nuances between the various terminologies. You are welcome to add to this list.

  • Smokeis produced as a result of combustion (temperature > 800o C). When combustion occurs, new chemicals are formed via the process of oxidation. Hence, smoke contains several new chemicals different from those initially burned. Smoke can be produced by burning coal, wood, cigarettes, bidis, etc.
  • Smokingis a practice in which a substance is burned and the resulting smoke breathed is absorbed into the bloodstream. The most common form of smoking is cigarette smoking or recreational drug use.
  • Second hand smoke:Smoke that fills restaurants, offices or other enclosed spaces when people burn tobacco products such as cigarettes, bidis and water-pipes.
  • Third hand smoke:It is not exactly smoke, but the “invisible” chemical residual of tobacco smoke contamination that sticks to clothing, wall, furniture, carpet, cushions, hair, skin and other materials in the environment after the cigarette has been extinguished.
  • Vaping:Act of inhaling and exhaling a vapor or an aerosol. E-cigarettes do not produce tobacco smoke, but an aerosol, which is commonly termed as “vapor”.
  • Vapor:When a substance becomes gaseous, at a temperature that is lower than its point of combustion (180-250oC), it is considered as vapor. Unlike smoke, the chemicals in vapor are the same as those found in the vaporized substance.
  • Aerosol:Suspension of tiny particles of liquid, solid or both within a gas.
  • Electronic nicotine delivery systems (ENDS) and Electronic Non-Nicotine Delivery Systems (ENNDS):Products that heat a solution to create an aerosol which frequently contains flavourants, usually dissolved into Propylene Glycol or/and Glycerin; the aerosol is inhaled by the user. Most common example are e-Cigarettes that that do not burn or use tobacco leaves but instead vaporise a solution the user then inhales. All ENDS (but not ENNDS) contain nicotine.
  • Heated tobacco products:Also known as “Heat-not-Burn” products, they produce aerosols containing nicotine and other chemicals, upon heating of the tobacco, or activation of a device containing the tobacco, which are inhaled by users, through the mouth.
  • Sheesha: Fruit-flavored tobacco, which is roasted in a foil along with charcoal and passed into a small chamber of water through a glass-bottomed pipe. It is then inhaled slowly.
  • Smokeless tobacco:It is tobacco that is not burned. It is also known as chewing tobacco, oral tobacco, spit or spitting tobacco, dip, chew, and snuff.
  • Chewing or spit tobacco:Tobacco in the form of loose leaves, plugs, or twists of dried tobacco that may be flavored. It is chewed or placed between the cheek and gum or teeth.
  • Guṭkha or pan masalais a chewing tobacco preparation made of crushed areca nut, tobacco, catechu, paraffin wax, catechu, slaked lime, flavoring agents and sweeteners
  • Khaini contains dry tobacco, slaked lime
  • Betel quid or pan: Contains betel leaf, areca nut, catechu, slaked lime and tobacco
  • Snuff or dipping tobacco:Finely ground “smoke-free and spit-free”” tobacco packaged in cans or pouches and may have flavorings added. Dry snuff is sold in a powdered form and is used by sniffing or inhaling the powder up the nose, while moist snuff is put between the lower lip or cheek and gum.
  • Snus:Type of moist snuff first used in Sweden and Norway. It’s often flavored with spices or fruit, and is packaged like small tea bags. Snus is held between the gum and mouth tissues and the juice is swallowed.
  • Standard drink:Definition of standard drink differs in countries: US = 14-15 gm alcohol equivalent to 12 oz beer, 5 oz wine and 1.5 oz 80 proof liquor; UK 8 gm alcohol, Japan 19.75 gm alcohol and India 10 gm alcohol

o     Alcohol content differs in various drinks: Beer 5%; Malt liquor 7%; Table wine 12%; Fortified wine (sherry, port) 17%; Cordial liquor (aperitif) 24%; Brandy (single jigger) 40% and 80 proof gin, Vodka, whisky 40%

o     Moderate drinking means less than 2 drinks per day (women) and less than 3 drinks per day (men) and for people aged more than 65, less than two drinks per day

o     Heavy drinking means more than 7 drinks per week or 3 drinks per occasion (women) or more than 14 drinks per week or 4 drinks per occasion (men).

o     Binge drinking means 4 or more drinks at one time (women) or 5 or more at one time (men)

  • Charas, hashish, ganja and bhang:are obtained from the cannabis plant.

o    Marijuana is another name for cannabis obtained from the Cannabis plant

o    Charas is the separated resin from the cannabis plant

o    Ganja is prepared from the flowering or fruiting tops of the cannabis plant

o    Bhang is prepared from the leaves (and seeds) of the cannabis plant.

(The Narcotic Drugs and Psychotropic Substances Act,1985 has banned the production and sale of cannabis resin and flowers, but permits use of leaves and seeds)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

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