"Life sans dignity is unacceptable defeat and life
that meets death with dignity is … a moment of celebration." Chief
Justice of India, Deepak Misra quoted Ernest Hemingway in The Old Man
and the Sea as he made a landmark judgment legalizing passive euthanasia
and approving "the living will." This judgment comes in the wake of a
string of judgments, which are paving the way for increased individual
freedom, including decriminalization of suicide.
The story begins in 2005 when the NGO ‘Common Cause’
filed a petition asking for permission for a ‘living will’ by persons
afflicted with a terminal illness with no hope of survival. There was
much public debate also when on a separate plea the court allowed
passive euthanasia in the case of Aruna Shanbaug in 2011. Finally on
March 9, 2018, the Supreme Court authorized families to switch off life
support for their kins if a medical board has declared that they are
beyond medical help.
A living will is a written document by way of which a
patient can give his explicit instructions in advance about the medical
treatment to be administered when he or she is terminally ill or no
longer able to express informed consent. Passive euthanasia, meanwhile,
is a condition where there is withdrawal of medical treatment with the
deliberate intention to hasten the death of a terminally-illpatient. However,
to prevent misuse, the Court has asked for stringent guidelines to be
fulfilled by various medical boards, including experts and judicial
authorities. This complex judgment has been deeply studied from all
aspects – medical, metaphysical, constitutional and religious – by Chief
Justice Misra and his colleagues, and an attempt has been made to uphold
individual dignity at a time when as he poetically puts it "the spring
of life is frozen and…life which one calls a dance in space and time has
become still." (The Times of India 10 March 2018)
Art Classes and Medical Students
A recent study on medical students of the University
of Pennsylvania has many lessons for those designing medical curriculum
anywhere in the world. Students underwent training normally reserved for
students of art history in the Philadelphia Museum of Art. They
participated in sessions on how to look at art –thatis observe and
reflect upon objects of imagination. This technique, called ‘Artful
thinking’ begins with approaching a piece of art with introspection and
observation before interpretation. After six 90-minute classes on art
observation by professional art educators, they were tested along with a
control group of students.
To assess the effect of art observation training, all
students in the study completed pre- and post-intervention tests. The
tests required students to describe in writing their observations of
three different types of images: art images, retinal images, and
external eye/face images involving ocular or periocular disease. For
example, the rubric for retinal images included points for correctly
describing specific observations of retinal hemorrhages with central
hemorrhagic cyst, ocular histoplasmosis, chorioretinitis, and
Stargardt’s Disease. Students who participated in art training had a
significant improvement in overall observational skills compared with
the control group.
In the United States, now 69 of the 133 accredited
Medical colleges require that a medical student take a course in medical
humanities. This includes courses in literature, visual arts, theatre,
philosophy,etc. The subliminal benefits range from improved
clinical skills, inculcating empathy, and reducing stress. Becoming a
good doctor is quite distinct from becoming a well-trained doctor. One
needs to be conversant with the larger world of ideas for that. (Opthalmology.2018;125:8-14)
WHO Guidelines on Management of Latent Tuberculosis
The WHO has tried to clear some of the ambiguities
surrounding prophylactic anti-tubercular therapy. So far, testing for
latent tuberculosis was targeted at patients living with HIV and
children below the age of 5 years who are contacts of patients with
tuberculosis. The net has been expanded to include older children,
adolescents and adults in contact with patients with tuberculosis and
contacts of patients with multi-drug resistant tuberculosis.
Either the tuberculin test or the interferon gamma
release assay may be used.Active tuberculosis may be ruled out in the
absence of clinical symptoms of cough, fever, weight loss or night
sweats and a normal chest X-ray. Testing for latent tuberculosis
before starting prophylaxis is not mandatory for persons living with HIV
or children below 5 years who are contacts of patients with
tuberculosis.
Besides the old regimen of 6 months of daily
isoniazid (INH), two new regimens have been recommended both in low and
high prevalence areas of tuberculosis. One is 3-month course of daily
INH and rifampicin. The other is a 3-month course of weekly rifapentin
and isoniazid. In areas of high tuberculosis prevalence, adults and
adolescents living with HIV and without active tuberculosis must receive
36 months of isoniazid prophylaxis, irrespective of their immune status.
Besides these guidelines, recently there has been
active experimentation in the area of prophylaxis in patients with HIV.
A recent study in 3000 patients with HIV has shown that a one-month
course of daily rifapentin and isoniazid has been as effective as a
9-month course of INH prophylaxis in HIV patients.
In the face of a rather bleak scenario where prophylaxis against
tuberculosis was received by a paltry 13% of the 1.3 million children
who deserved it, the WHO guidelines are most timely. (http://www.who.int/tb/features_archive/WHO_
recommendations_TB_prevention/en/).