Healthcare undeniably needs to be regulated. Further, such regulation needs to be constantly updated and relooked at, to keep abreast of new developments in the industry and constantly progressing technology. Currently there are two issues doing the rounds for regulation; the issue of “Guidelines for Withdrawal of Life Support”; and second, the NMR development of a central register for all medical graduates practicing in India.
A gazetted notification was released on August 5, 2024 titled “Guidelines for Withdrawal of Life Support”. This was a culmination of numerous judgements spread over many years.
In 1994 came “Rathinam vs Union of India” which held that the constitutional right to life implied the right to die. This was overturned in “Gian Kaur vs State of Punjab” (1996), which held that the Constitution did not give you the right to die, but introduced the concept of the right to a dignified life as well as a dignified death under Article 29.
In 2011, “Aruna Shanbaug vs Union of India” recognized that life supporting systems could be withdrawn in certain circumstances. The term “passive euthanasia” was introduced as permissible and distinct from “active euthanasia” which was not permitted. The legislature was directed to draft guidelines for withdrawal of life support systems in specified situations.
In 2018, disposing of a petition in “Common Cause vs Union of India” the right to die with dignity was established as a fundamental right under Article 21 and legalised the use of advanced medical directives or “living wills”. Guidelines were laid down in this judgement, again directing the legislature to draft an act.
In 2023, in “Common Cause vs Union of India” the process of making “living wills” and withholding/withdrawing life supporting treatment was simplified, reducing government involvement.
The notification of August 5, 2024, called for suggestions to be submitted by October 20. It includes a flow chart to simplify the description of the procedure. This directs the setting up of Primary and Secondary Medical boards by a hospital to determine if and when further medical treatment will cease to be of any benefit to the patient.
The Chief Medical Officer will nominate doctors to the Secondary Boards based on specialty and experience to scrutinise the opinion of the primary boards and confirm or reject their opinion. Members of both boards must be subject experts with at least five years experience.
If rejected, the matter goes back to a court on appeal or to the hospital for review of the procedure. If accepted the local judicial magistrate is notified.
In the processing of new draft legislation, the powers that be usually consult leading figures in the field for technical inputs. These consultants are most often attached to major urban corporate multi-specialty units run on business models.
Most of the problems in healthcare are to be found in the rural “mom and pop” type hospitals run as family units. In far-flung rural areas, compliance with the specialist requirements will be very difficult indeed. In any case, why would two medical boards be required to settle one matter? It appears to question the competence of the primary board. Whilst this decision making is in progress, the patient may be languishing in the ICU, with rapidly increasing hefty bills.
The process should be strictly time bound to be completed in 24-48 hours, by one appropriately selected medical board.
The second issue is the National Medical Commission (NMC) developing a central register to establish the number of medical graduates in the country.
The right to practice anywhere in the country, often causes duplication of registration with multiple state medical councils for doctors practicing in more than one state. The website for the purpose of registration appears to have been designed by a techie with blinkers on and very little knowledge of ground realities in healthcare.
Gross mistakes are noted in the existing Indian Medical Register as uploaded by state medical councils with buck-passing on to “previous office bearers”.
This was side-tracked by uploading the personal profile using Aadhaar card details. Changes in names of institutions were not catered for. For example, many older graduates in Goa had their degrees conferred by the Bombay University and later by Goa University when that came into being. This option was absent in the initial website and required intervention by the local Registrar.
The qualification conferred by the Portuguese “Escola Medica” finds no place in the website. Many degrees were conferred in pre-Aadhaar days and the names did not exactly match the one in the Aadhaar card. This had to be rectified by a supporting affidavit. In some south Indian communities’ names do not follow a pattern of surname/family name and given name.
In Kerala, the registering council was “Travancore- Cochin Medical Council”, which became the Kerala State Medical Council in 2021. This change is not recognised or catered for by the website, and the applicant is expected to approach the SMC for rectification.
Senior graduates in West Bengal have their degrees conferred by Calcutta University. This has now become the West Bengal University of Health Sciences, again not recognised by the website. The required changes have to come from the SMC some of which, like West Bengal, are dormant and barely functional.
Emails to the address given for redressal in the NMR website do not elicit any acknowledgement, let alone resolution. Phone calls to the given number 14477 elicit a reassurance that the matter will be looked into. A simple issue has been savaged into a major problem.
The list of all registered medical practitioners taken from the State register, could have been uploaded into a central register, leaving those graduates practicing in multiple states to apply for special registration. This could have been followed by a State-wise verification process to exclude imposters. It appears that there were considerations other than user-friendly practicalities when the website designing was assigned.
(The author is a past IMA Goa State President, a founder member and past President of VHAG, and a healthcare activist)