THE NATIONAL MEDICAL JOURNAL OF INDIA

CorrespondenceVOL.2, NO.5 249

Brain death

Sir-If we have to determine brain deathwell before cardiorespiratory death, wemust define this term. This definition mustbe legally, and more important, socially,religiously and morally accepted.

To make clear the Hindu view, let meremind you of the allegory related byBhishma to his grandson Yudhisthir. OnceMaharishi Vyasa saw an insect runningaway from a cart. He asked the insect whyit had done so. The insect replied, 'Deathis terrible, so I want to save my life. Life isdear to any soul. I get pleasurable objectsto enjoy. Please help me.' Vyasa said, 'Anindividual whose speech, intellect, handsand feet are gone (the functioning of theseorgans has ceased), what does he get if helives long? If a Brahmin, a man of goodnature and character, serviceful to societylives long, he does more good to theworld.' The insect agreed and did notmove from the track of the cart and waskilled (Mahabharata. Anus. P Ch. 117).7 October 1989 Swami Vipashananda

Ramakrishna Mission HospitalBombay

II

Sir-Common sense demands that ourlaw on death is suitably updated to permitsupport systems to be withdrawn and valu-able organs retrieved. However, thechanges must take note of public opinion,race experience and our thinking over theages on this subject.

All civilizations have upheld the integrityand sanctity of the human body. In Indianliterature, the body has been described asa temple, the abode of the Lord. It musttherefore be kept very clean. Indeed allmorality-the entire range of taboos andtotems-has but one aim: the good healthand long life of man. For millennia, thehuman body was considered so inviolablethat man did not think it safe or right evento cut hair given by God. Such shaving, itwas feared, may invite divine displeasure.

There are many references to the graftingof whole organs in the ancient texts. Twoof the twenty-four Hindu avatars areNarasimha, half-man half-lion, andHayagriava, half-man half-horse. Andthen of course there is Ganesh, half-manhalf-elephant.

In Islam we have Burruq, the winged

horse which carried the Prophet to heavenat the speed of electricity. The ancientWest always had mermaids, half-fish half-woman. And the pre-Islamic Middle Easthad a model of perfection in a being-Lamassu-with the head and face of aman, the body of a lion and wings to fly!All these were obviously imaginary andnot real. But they were acceptable models,not horrifying demons.

There are two well known instances inancient Hindu texts of transplantation oforgans. Indra seduced Ahalya, wife ofGautam Rishi, and Gautam in his ragecursed him to impotence. Indra then saidto the Devas: 'By obstructing the asceticpractices of Gautam, I have served thepurposes of the Gods. By evoking hiswrath, I have robbed the Rishi of hisspiritual powers.' The grateful Devas thengrafted a ram's testicles onto Indra.

And then there is the case of BhagvanMahavira. He was conceived in the wombof Devanand, a Brahmani; but Indra sentan agent to transfer the embryo to thewomb of Trishala, the wife of the kshatriyaSiddhartha.

Shukracharya, when he grew old, isbelieved to have been gifted a secondyouth by the youngest of his four sons andGokarana had the ears of a cow.

The Hindu, therefore, can have noobjection to the transplanting of organsfrom brain dead persons to ones needingsuch organs. One can only admire a personwho donates an organ to a close relative ora friend. However, we must be carefulthat we protect poor people selling theirkidneys to the rich. No religion or culturewill sanction making a business out ofhuman organs.12 October 1989 K. R. Malkani

Deendayal Research InstituteNew Delhi

III

Sir-Islam considers life to be a sacredpossession handed over to man. He issupposed to take great care of it so that hisprimary duty of worshipping the Almightyand fulfilling the responsibilities towardshis fellow men can be undertaken withoutany disruption. Hence, taking one's ownlife is a heinous crime and haram (prohi-bited) and under no circumstances musthuman life be damaged or destroyed.Since man is simply a 'trustee' of 'life'

which belongs to Allah, he is expected touse it in the 'Path of Allah'. The accom-panying characteristics and features of lifeare also given to him by the Almighty, andthey too must be utilized for achievinghigher goals (establishing the Islamic wayof life, creating a just order based onIslamic values etc.).

It is in consonance with this concept ofsanctity of life that a Muslim is required totake whatever steps necessary to save life,with a conscious realization that survivaldepends solely on Allah's wish.

It is also the Prophet's Sunnah to consultthe physician and take medicines. Henceall kinds of medical treatment, includingsophisticated life-supporting systems canbe availed of, provided a Muslim or thesociety in which he lives can afford them.

For a Muslim, this life is merely a briefstopover in the ongoing journey to the'after life'. Belief in 'Predestination' is apart ora Muslim's faith. Death, therefore,occurs at an appointed hour. The Prophethas said: 'Every disease has a cure exceptold age and death.'

Because of the great strides in medicaltechnology there is a growing feeling inMuslim society .that certain problemsrelating to the definition of death shouldbe reconsidered. The Muslim WorldLeague (Rabata-Aalam-e-islam) based inJeddah has issued a fatwah favouringorgan transplantation. This is consideredto be a landmark decision considering thatopinion is still divided on this issue. Promi-nent Islamic Muftis (scholars of Islamicjurisprudence) in India and Pakistan (theLate Mufti Mohammad Shafi of Pakistan,the Late Maulana Maudidi and MuftiAtiqur-Rehman Sambhali in this country)have however always opposed organtransplantation. Their arguments runthus:

As long as visible signs of life are present, apatient can not be called as dead.'

By removing organs from an individual'sbody, the doctor shows utter disrespect tothe human body which is neither his nor thepatient's. His act, in other words, is interfer-ing with the divine arrangement of Allah.

Nevertheless, even in India, someIslamic scholars have realized thatbecause of recent medico-legal problemsthere must be a reinterpretation offunda-mental Islamic principles. It was thisthought that motivated the Amarat-e-Shariat in Bihar and its moving spiritMaulana Mujahid-ul-Qasimi to organize aseminar in 1988 on some contemporary

250

issues. One of the topics discussed therewas 'Organ transplantation'. You shouldrequest the Maulana Sahib for his viewson this controversial subject.25 September 1989 Syed Iqbal

Bombay

IVSir-The editorial 'Brain death and organtransplantation'! could not have come at amore appropriate time, considering therecent spate of advertisements (I prefer tocall them tender notices) saying 'Wantedkidney, Donor will be suitably rewarded'(or is it that seller willbe handsomely paid).

The editorial hopes that the legislation onbrain death being prepared by the Ministryof Health will reduce the iniquitous andopen trafficking in donor organs for finan-cial gains. But the Government, theMadhya Pradesh Government at least,seems to be moving in the reverse direc-tion. It has decided to grant a special leaveof 7 days, total expenditure incurred onoperation and Rs 10 000 as incentive to itsemployees who donate (sell) their kidneyto patients other than their near relatives.fthus officially patronizing sale of organs.20 October 1989 V. K. Kapoor

LucknowREFERENCES1 Anonymous. Brain death and organ trans-

plantation. Natl MedJ India 1989;2:157-9.2 Anonymous. MP incentives to kidney

donors. The Hindustan Times 1989:9 Oct.

Is it Crohn's disease?

Sir-In the article 'Distinguishing Crohn'sdisease from intestinal tuberculosis" theauthor has pointed out (in Table I) thatthere is considerable overlap in the clinicaland pathological profiles of the two dis-eases. Thus, it is rare to make a correctclinical diagnosis of Crohn's disease inIndia because tuberculosis is so muchmore common and most of us are notlooking out for Crohn's disease. Further,one hardly ever sees a typical case of thisdisease in this country. In my experienceof about five years in Delhi and Calcutta,I have seen only four patients who afterlaparotomy were ultimately diagnosed tohave Crohn's disease. All four were males.in their early forties and presented withlong (2 to 10 years) histories of irregularbowel habits. The symptoms had alsoresponded temporarily to anti-amoebicdrugs. Only one patient had enteric fistulae.The others presented with lower gastro-intestinal bleeding (during a therapeutic

THE NATIONAL MEDICAL JOURNAL OF INDIA

trial of antituberculous drugs) and had toundergo operation, which ultimately con-firmed the diagnosis.

This leads me to another question. Is 'ourCrohn's' the same disease as that whichoccurs in the West. The gastrointestinaltract has only very limited ways ofresponding to an immune stimulus. It hasbeen shown that a high percentage ofpatients with irregular bowel habits inIndia have circulating amoebic antigen-antibody complexes- which tend tobecome deposited in the colon. Here theymay activate complement pathways andgenerate an inflammatory response.Perhaps many of our so-called 'non-specificcolitides' have such a background. It willbe interesting to investigate whether 'ourCrohn's disease' is related to an immunereaction to amoebic antigen.15 October 1989 Maj A. C. Anand

Command Hospital (EC),Alipore, Calcutta

REFERENCES1 Anand BS. Distinguishing Crohn's disease

from intestinal tuberculosis. Natl Med JIndia 1989;2:170-5.

2 Jalan KN, Maitra TK. Amoebiasis in thedeveloping countries. In: Ravdin 11 (ed).Amoebiasis. New York:lohn Wiley, 1988:535-55.

Indian doctors smoke too much

Sir-We studied in 1987 the pattern oftobacco consumption among male medicalstudents, hospital residents and teachersin the Sawai Man Singh Medical Collegein Jaipur and compared our results withthose of a similar study done in 1964.

METHODSInformation from 242 medical studentswas obtained using a questionnaire, and148 residents and 174 teachers. were ques-tioned directly by their close associates.The earlier study in 1964 involved 386students, 268 residents and 129 teachers.The Chi-square index was used for statisti-cal comparison.

RESULTSThere was some variation in the tobaccoconsumption among the different batchesof students and residents (range 18-36%)(Table I). Most of the respondents smoked;no student chewed tobacco exclusivelywhereas 3% of residents and teachers did.

A significantly smaller proportion (34%vs. 24%; p<O.OI) of students consumedtobacco in 1987 than in 1964 (Table II).Although fewer residents and teachersused tobacco in 1987 than in 1964 theproportion was not significantly less.

VOL. 2, NO.5

We compared our data with thoseobtained in 5 studies'< on smoking habitsin medical students, physicians and nursesin the United Kingdom and the UnitedStates of America carried out between1948 and 1982 (Table III). We found thata larger proportion of Indian medicalstudents and teachers use tobacco.

DISCUSSIONThe prev.alence of tobacco consumptionobserved in the present study is28% amongmale medical students and teachers. This

TABLE I. Pattern of tobacco consumptionamong medical students, residents andteaching staff, 1987

Group Total Tobacco consumersnumber

Total smoke chew bothII(Uio) , 11(%) n(%)

Students 242 57 38 19(16.0) (8.0)

Residents 148 52 42 4 6(28.4) (3) (4.0)

Teachers 174 51 29 16 6(17.0) (9) (34)

TABLEII. Comparison of tobacco consumptionbetween 1964 and 1987

Group Year Total TC pvalue

Students "1964 386 1311987 242 57 <0.01

Residents 1964 268 109 NS1987 148 52

Teachers 1964 129 58 NS1987 174 51

TC Tobacco consumers

TABLEIII. Comparative study of tobacco usein USA and Japan

Medical StudentsAuthor Year % smokers

1948-57 31

1967 231977 14

1978 6

1964 34

1987 24

Year % smokers

1959 391963 321965 281972 201982 17

1964 43

1987 26

Thomas-Foley et al.?Birkner & Kunze]

Coe & Cohen"

SMS·

SMS

Physicians

Study

CPS1'

CPS II'

SMS·

SMS

CONFERENCE REPORT

is higher than that in another study fromfive other medical colleges (8% to 11%).6However, the incidence elsewhere may below because the population studiedincluded female students in whom smok-ing is rare and the numbers studied weresmaller-only 241 males and 114 females.In yet another study from a medical collegein Bombay the incidence of smokingamong male students was reported to be31%7 which corroborates our findings.

India ranks third in the world in termsof production and consumption of tobaccoand its products. The incidence of tobaccoconsumption in rural areas varies between44% and 74% and in the urban populationthe pattern appears to be similar. 8 Theincidence of smoking among medicalstudents and teachers is lower than that inthe general population, but it is still highwhen compared with figures from westernmedical schools (Table III).!-5 A wellplanned, broad based anti-smoking cam-paign starting in the schools is urgentlyrequired.7 October 1989 R. K. Sogani

Rajshri MisraA. K. Gautam

Jeev Raj JatDepartment of Internal Medicine

SMS Medical College, Jaipur, India

REFERENCES1 Garfunke1 L, Stellman SD. Cigarette smoking

among physicians, dentists and nurses.World Smoking Health 1986;11:4-9.

2 Thomas GB. Characteristics of smokerscompared with non-smokers in a populationof healthy young adults. Ann Intern Med1960;53:697-718.

3 Birkner FE, Kunze M. Smoking pattern at aBritish and American school. Med Educ1978;12:128-32.

4 Coe RM, Cohen JD. Cigarette smokingamong medical students. Am J PublicHealth 1980;70:169-71,

5 Foley WD, McGinn ME, Amoe HE.Cigarette smoking among medical students.N Engl J Med 1969;280:1284-5.

6 Behara D, Malik SK. Smoking habit ofundergraduate medical students. Indian JChest Dis Allied Sci 1987;29:182-4.

7 Pandit DD, Jha SS. Knowledge of tobaccosmoking in medical students at TopiwalaNational Medical College, Bombay. IndianJ Community Health 1988;4:29-37.

8 Gupta PC. Health consequences of tobaccouse in India. World Smoking Health 1988;13:5-10.

9 Sogani KC, Sogani RK. Doctors, medical stu-dents and nicotine consumption. RajasthanMed J 1964;4:299-303.

Unnecessary hospital admissions

Sir-Medical care is becoming increasinglyexpensive and this is especially true ofhospital care.' Unlike western countries(where most of the people are insured),the majority of Indians have to beardirectly the cost of hospital treatment.Many consultants still recommend hospitaladmission even when it is not required.Often the cause for hospital admission isinvestigations which can be done on anoutdoor basis. The doctor has become abusinessman.? the profit motive obscureshis ethics and he has no compunction inmaking the patient spend money on anunnecessary hospital admission. Thisattitude is prevalent in every specialityof medicine. I would request my fellowdoctors not to make people suffer as mostof them are already poor. Let us onlyadmit patients to hospital in the interest ofthe patient's health and not of our bankbalance.18 September 1989 R. S. Bhatia

Ludhiana

REFERENCES1 Bhatia RS. Why people instead of patients

are hospitalized? J Assoc Physicians India1989;37:412-13.

2 Dave D. Economic pressures dilute medicalethics. Medical Times 1988;18:2.

Conference Report

251

The risk of HIV infection

Sir-Screening of donated blood forHuman Immunodeficiency Virus (HIV)infection on a regular basis was mademandatory in the USA in the spring of1985.! We studied 32 Indians who hadundergone major surgery in the USA (18),UK (12) and Canada (2), between 1980and 1985for the presence of HIV antibodyusing a commercial HIV-EIA kit. Of the32 cases, 29 had coronary bypass surgery,2 had a kidney transplant and 1had a stag-ing laparotomy for Hodgkin's disease. Innone of the 32 individuals were HIV anti-bodies.found. Our finding suggests thatthough HIV screening was not mandatorybefore 1985, the chance of contractingHIV infection through transfusion at thattime was low.7 September 1989 Arvind Rai

S. KumariAIDS Reference Laboratory

Division of Microbiology.National Institute of Communicable Diseases

Delhi

RE,FERENCE1 Human immunodeficiency virus infection in

transfusion recipients and their family mem-bers. MMWR 1987;36:137,..40.

Erratum

In the article 'Oxygen therapy in clinicalpractice' by N. Korula (Natl Med J India1989:2:195-8) on page 195, column 2,line 5 from the bottom should read-'The inspired oxygen tension in a personbreathing room air at sea level is 150 mmHg'. The error is regretted-Editor.

Writing Biomedical Papers and Writing, Editing and-Publishing of Medical Journals. 9-11 March 1989,Lucknow, India.

cisely in English. As a result, only a small proportion ofIndian research was published in international journals.He hoped that courses in medical writing such as thesewould be held more frequently in the future.

The first session was devoted to structure, grammar andstyle. It was emphasized that writing should be plannedand simple. Sentences and paragraphs should be short,devoid of eccentricities of language. Dr Philip Abraham(KEM, Bombay) said that the most frequent mistakes

l. WRITING BIOMEDICAL PAPERSDr S. R. Naik (SGPGIMS, Lucknow) introduced thecourse by stating that the aim of writing and publishingwas to communicate, and that most Indian scientists faceddifficulty in expressing themselves adequately and pre-