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Last Updated: Monday, 23 July 2007, 09:38 GMT 10:38 UK
Indian patients suffer in silence
By Dr Daniel Sokol
Medical ethicist

Daniel Sokol
Dr Sokol was startled by the differences
Medical ethicist Daniel Sokol gives a personal account of his experiences in Tamil Nadu, south India, working with a surgeon in a rural hospital.

Two weeks ago, I was in a hospital in Stoke-on-Trent, lecturing to a group of doctors on informed consent and truth-telling.

I stressed the importance of respecting patients' wishes, even if they clashed with our own, and reminded my audience to consider when, where and how to tell the truth.

Disclosing a grim truth at the wrong time or in too blunt a manner can be harmful to patients and their relatives.

Doctors are highly respected figures in India. A 10-year-old boy wears a T-shirt which reads 'future doctor'.

Last week, after an 11-hour plane journey and a perilous 6-hour taxi ride, I arrived in the Indian state of Tamil Nadu where, for the next month, I shall be observing the work of a rural surgeon.

In the morning, the surgeon acts as a surgically-trained GP, seeing patients as they walk in from the street.

He drains abscesses, cleans wounds, checks orifices, and treats infections of all sorts.

The afternoon is devoted to surgery.

An appendix is removed here, a uterus there, haemorrhoids sliced off, a hernia repaired, a gaping wound stitched up.

Traffic accident patients

The 20 or so rooms in the hospital are small, basic and crowded.

Travel in India can be chaotic and dangerous

In some rooms, every inch of space is filled by relatives, sometimes as many as ten, sitting on the floor.

The ceiling fan can do little against the flies and the sweltering heat.

After my hair-raising car journey from the airport, I was not surprised to find many of the rooms occupied by victims of road traffic accidents.

Those that are not are usually inhabited by diabetic patients, too often with wounds so large and deep that the muscles and bones are exposed below.

In one of the rooms lies Rajendran, an elderly diabetic man, with a bandaged foot leaking brown fluid.

His foot is so gangrenous that it cannot be saved. He will undergo an above-knee amputation.

The next day, I help hoist Rajendran onto the operating table.

He is scared, muttering quietly to himself as the spinal anaesthetic is administered.

The surgeon makes a deep incision above the left knee, and cuts away through the fat and muscles until he reaches the bone.

The bone is cut using what looks like a cheese wire.

After a few more strokes with the scalpel, a nurse lifts the severed leg from the table and dumps the heavy object in a plastic bowl.

No informed consent

The following day, the surgeon and I are driving to nearby villages to fix a perforated ulcer in a young man's intestines and to stitch up a lady's poorly closed Caesarean wound.

As we overtake an elephant on a truck, he tells me Rajendran was unaware of the amputation. When he first suggested the procedure, Rajendran refused.

The poor prognosis without surgery - another month or so of life - did not change his mind.

So his family told him that the surgeon would simply fix his thigh.

This, they said, would allow the blood to flow once again to his foot. He reluctantly agreed.

As I write this, three days later, Rajendran still doesn't know the truth.

Although he notices his lower leg is missing, he believes it will be reattached once the wound is healed.

As the junior doctor observed on my first morning at the hospital, most patients are not medically sophisticated.

This ignorance in matters medical, as well as the consultation fee of 50 rupees (roughly 75p), is partly why patients seek medical help much later than in the UK.

Botched circumcision

Yesterday, a 70-year-old woman walked in with an advanced carcinoma of the uterus.

For some patients, a "small" growth is one that can barely be seen a mile away

The prognosis is bleak. For the past six months, some of her relatives encouraged her to see a doctor but she waved off their concerns, saying she would get better at home.

Minutes later, a 60-year-old man sits next to the surgeon and whispers a few words in his ear, smiling nervously.

Since his circumcision 20 years ago, something wasn't quite right down below.

When he removed his underwear, the tip of his penis was missing and the remaining tissue was covered in tarry craters, like miniature volcanoes covered in soot.

To treat the carcinoma, the surgeon will have to remove the penis and the scrotum.

It is only because the craters blocked his urethra and affected his peeing that he visited the doctor.

For some patients, a "small" growth is one that can barely be seen a mile away.

Different to the West

In the UK, the ethical principle of respect for patient autonomy prohibits deception.

Hospital room
Facilities can be basic

Competent adults can refuse any procedure, however life-threatening and for whatever reason.

Here, patient autonomy can be trumped by the autonomous wishes of the family.

There is a strong spirit of community and family responsibility at odds with the Western focus on individual choice.

The surgeon is certain that Rajendran will come to accept his relatives' decision.

Doctors are highly respected figures in India. A 10-year-old boy wears a T-shirt which reads 'future doctor'.

A letter from an X-ray lab to the surgeon starts with "Respected doctor".

Patients are submissive and the paternalistic dictum "doctor knows best" prevails.

I am still shocked by the surgeon's angry outbursts.

Doctor shouts

This morning, a 22-year-old man enters the consultation room.

After a brief exchange, the surgeon asks the female junior doctor and the nurses to leave the room; a tell-tale sign that the problem is located in an intimate area.

The patient pulls down his underwear and lies face down on the bed while the surgeon pushes a hollow metal instrument - a proctoscope - deep in his rectum.

The patient winces in pain. The surgeon shouts at him, slapping his buttocks and telling him to stop clenching.

"Look", he tells me, "can you see the change in colour?".

Down the proctoscope, the pink mucosa turns a darker red. The patient has haemorrhoids.

As I reflect on these events, I smile at the thought of the surgeon and his nurses attending my lecture in Stoke-on-Trent.

No doubt they would have been bemused and concerned by our obsession with respecting patients' choices, however foolish these may appear.

For my part, I wonder how Rajendran will react when he discovers the truth.

  • Dr Daniel Sokol is a medical ethicist at St George's Hospital Medical School, London, and Director of the Applied Clinical Ethics course at Imperial College London. www.medicalethicist.net

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