ABSTRACT
Under the current practice in organizing surgical services, proportionate representation of disciplines is provided in the curricular planning and in corresponding clinical functions. This is based on the level of competence expected by the end of training period. The disciplines as a “whole” are placed in general surgery or super specialty. The system of vertical arrangement has some serious concerns. Paradoxically, patients with diseases of simple and routine nature of discipline categorized as super specialty are neglected. Super specialist is unable to attend on account of preoccupation with serious challenging problems. The general surgeon hesitates because of privileging issues, fear of allegations of negligence and litigation. The system of vertical division is based on premise that some disciplines deal with complex procedures and others with only simple and routine nature. This premise is incorrect. Each discipline is a mix of simple and complex cases requiring specialized treatment. Alternate modified organization of surgical service is proposed. Activities of all disciplines are scrutinized according to the level of expected competence by the end of training. Categorization is shifted from the “discipline' to “activities.” Criteria applied for classification of activities are as follows: on completion, the trainee is capable to assume full responsibility-category 1; has gained sufficient experience-category 2; and is conversant with broad understanding of management-category 3. Activities of category 1 from all disciplines are assigned to general surgery and those of category 3 from all disciplines are assigned to respective super specialty. Those in the middle, comprising difficult cases but not requiring specialized training or heavy inputs in equipment, are in category 2. They are assigned to general surgery as additional/optional items, or super specialty, guided by local factors. The scope and practice of general surgery are broadened with a shift from “residual” to “comprehensive” discipline. Advantages, concerns, collateral issues of horizontal distribution of activities, its positive impact on research and education are discussed. It is concluded that the proposed organization of surgical services is a rational, logical, and practical strategy for good-quality surgical care in the society. The super specialists need to be convinced that “taking load off” is good for the specialty.
ABSTRACT
Euthanasia is mercy killing to alleviate the pain and misery of moribund persons. The thought in this regard is “Right to Life” includes “Right to Die.” This paper examines the issue of euthanasia in advanced stage of terminal cases with no possibility of reversal and it has been argued that there is a case for lifting euthanasia from the domain of human rights “Right to Die,” bringing the issue as a matter for professional opinion, a kind of medical advice/prescription. Guidelines need to be framed and criteria are laid down and notified under which euthanasia can be recommended. The decision is taken whether or not the criteria laid down are fulfilled in an objective manner. Like for other medical interventions “informed consent” is essential. In consideration of safeguards the decision is entrusted to a medical board and is subject to a legal prescrutiny. Professionally prescribed decision will to a great extent reduce emotive response surrounding euthanasia. The family may not have to face a difficult dilemma in deciding about euthanasia. There may not be a necessity of “living will,” although it may still be useful. The change to treat euthanasia as a professional decision/medical advice will require making legal and administrative provisions to empower medical establishment to discharge responsibility of euthanasia. It is essential to legalize euthanasia with corresponding modifications of medical ethics and code of conduct prescribed by Medical Council of India, State Medical Councils, and other regulatory bodies. It is essential to identify the procedure for carrying out euthanasia and the personnel assigned to actually carry out. Injection of lethal substance in lethal dose may be a favored choice. Once final decision after legal prescrutiny is arrived for euthanasia, differentiating passive and active euthanasia is unnecessary. In one perspective, active euthanasia is less disturbing for the patient, family, and friends as withdrawal of supporting tubes leading to dehydration, wasting, and struggling for breath associated with passive euthanasia, which nullifies the basic tenet of euthanasia, can be avoided. There is a possibility of spill over benefit of “active euthanasia” in the form of opportunity to promote cadaveric organ transplantation. Caution has to be exercised for effective safeguards to prevent misuse. There is a case for consideration for brining decision-making process regarding euthanasia within medical professional assessment and implementation