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Ethical issues in botched up eye surgeries

Dr. R.Kumar, Senior eye specialist &

President Society for promotion of Ethical and Affordable health Care

Recent reports of crop of failed eye surgeries from several hospitals of Haryana brought into focus the failure to assure vision to cataract patients even after successful surgical procedures by experienced surgeons and meticulous observance of operation theatre (OT) protocols. Studies revealed that such painful surprises have been occurring across the nation, in  private as well as public hospitals! We all recognize and accept that adverse events do occur with some frequency after any surgery including eye surgery, but should the blame squarely lie on the operating surgeons?  Failure of surgery coupled with blanket  charge of negligence on doctors, is not only heinous for the surgeon and gloomy for the patient, it obfuscate the underlying core issues and unduly exposes the doctor to hysterical anger of society, physical assaults, and avoidable litigation by the kith and kin. While most consumers have come to expect defect-free electronic gadgets, the medical scientists are loath to accept the same perfection into the delivery of surgical care. Various investigations and studies have revealed that cause of infection was detected in the fluids, medicines or instruments used in the surgery, in which doctors had no role to play! In a judicial review of failed eye surgeries Madurai bench of Madras High Court had acquitted the doctors from charge of negligence, while observing that ‘prosecution had failed to prove that doctors had any motive to cause harm’. No lack of skill or negligence was proved in the court, either.

There are several factual and ethical issues within the practice of surgery that have plagued the outcome and its acceptance: i) A cure or good outcome cannot be guaranteed, only possibilities can be predicted ii) inadequate knowledge about the incidence of adverse events, iii) inadequate practice guidelines or protocols, (iv) Failure to appreciate the fact that surgeon is only one player in the long chain of service and material providers, v) Existence of hospital acquired infections in almost all hospitals vi) Expectation of five star facilities even in free camps vii need to compensate affected patients viii) difficulty in truth telling and culture of blame game  ix) Doctors being soft targets

What botching up means

Dictionary meaning of botching up is   ‘To perform poorly or ruin through                  clumsiness or ineptitude’. It means lack of skill or negligence on the part of surgeon. That is not a fact in case of failed eye surgeries. Barring exceptions, most of the surgeons of failed surgeries had long experience, adequate qualifications and surgical skill and had no reason to see poor outcome. However, in some cases it was reported that due to callousness of supporting staff in the OT, or environmental conditions in and around the place of surgery or recovery, unhygienic conditions at home after discharge, existing infection in some other organ of patient or his care givers or failure to comply with the antibiotic regimen or other medication in the pre or post surgical period were the reasons.  No doubt doctors need to counsel Patients about the risks of eye infection and its prevention.  But can the surgeon ensure compliance?

Quack Surgeons

Only one in five doctors in rural India are qualified to practice medicine or surgery, as per a World Health Organization report on India’s healthcare workforce. Many of these unqualified doctors used to conduct free eye camps. Such surgeries, used to have compromises on several accounts:  unhygienic surroundings and set up, inappropriate OT, inadequate or unclean water for surgeons’ hand wash, untrained assistants, unsterilized linen, dirty and blunt instruments, poor quality of fluids and medication, lack of follow up after surgery, and lack of education among family members to look after the operated patients at home. Some quack surgeons may still be operating. The failed surgery patients would generally rush to hospitals like PGI and strangulate the already choked services. Despite technology, skill and dedication prevailing at these centers, the outcome would be dismal in large number of such cases. No hospital can guarantee cure or absolute protection against adverse outcomes!  Media had carried reports of an adverse event at ‘advanced eye centre’ (AEC) PGI a couple of years ago. Here a score of patients suffering from retinal problems were given Avastin injections into their eyes. All those injected with a particular batch of the drug developed inflammation in their eyes. It was after a great effort that these eyes could be saved. Were the doctors negligent?

Similarly things can go wrong in cases of other eye surgeries. LASIK  (laser-assisted in situ keratomileusis) is an example.  Eye specialists receive disappointed patients off and on, who were expecting to get rid of ugly spectacles, after Lasik.  In case of Lily 21 the euphoria of spectacle free face evaporated fast.  She was left with a feeling in her eyes as if " pins and needles were stabbing them". The victim prayed in vain for the status quo ante to be restored. Few others were driven to suicidal tendencies when left with perpetual pain, discomfort, dryness, disorientation, headaches, nausea, glares and inability to drive or work.  Morris Wexler, the man who led FDA team to approve LASIK, now says it was a mistake! There is a need for Message of warning for each case considering Lasik, as the conundrum of failed surgeries rages on!

Lack of control

Several whistle blowers have highlighted scams and manipulation issues in the pharmaceutical industry from time to time. The country needs strict criminal prosecution against suppliers of substandard drugs on the one hand and over-pricing on the other. Despite some recent reforms, the pharmaceutical sector is not marketing uniformly standard medicines, injectables, fluids, devices etc. If the infection occurrs due to poor quality of drugs, who should be tried?

Once substandard medicines are banished from the market, many problems of ‘botching up’ of surgeries will subside. This will also develop faith in generic medicines and poor will get affordable health care.

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