Max Hospital: Stuck Between Lack of Guidelines & Medical Ethics?
Even after desperate measures like life support system, the foetus would stand a very slim chance of less than half a percent of making it even for a few days.
Even after desperate measures like life support system, the foetus would stand a very slim chance of less than half a percent of making it even for a few days.(Photo Courtesy: Twitter/@pratidintime)

Max Hospital: Stuck Between Lack of Guidelines & Medical Ethics?

A lot of heat has been generated and a lot of dust has been raised for the past one week on two cases involving private hospitals in Delhi NCR which have been discussed ad nauseam in the print, electronic and social media. Fortis hospital charged a bill of Rs 15 lakh for 15 days, and by the end of it, a 7-year-old patient of dengue passed away. A few days later, Max declared an infant dead which was later found to be alive.

It appears that what is being lapped up and consumed by the public is not even half-baked truth. Passions have been fanned and emotions raked up. It will not be an exaggeration to say that the unfortunate events have been sensationalised and healthcare has been criminalised.

Therefore, the facts need to be checked.

What has been made out to be the death of a ‘baby’, is actually more complicated. The newborn does not even qualify to be defined as a baby.

The twins delivered at 22 weeks of gestation would technically be called foetuses and not babies. At this weight and at this period of gestation the foetus is not viable; in other words, not fit for survival outside the mother’s body.

Even as per American standards, they are best not resuscitated as a matter of accepted practice. Even after desperate measures like putting the foetus on life support, it would stand a very slim chance (less than half a percent) of making it even for a few days.

Such a foetus may have signs of life like twitching movements or heartbeat for a few hours and in very rare cases for one or two days. Further, a condition called suspended animation is known to occur in very premature births. This results in stoppage of breathing and heart rate for quite sometime and then resumption.

But unfortunately those babies almost never survive. This may be what happened in the present case. (Just as I write this, news has come that the living foetus in question has expired).

Also Read: Max Hospital Row: Newborn dead, parents refuse to collect body

Such desperate measures in any case would be deemed to be unethical. In the US, it is a given that resuscitation may not be done in any foetus of less than 22 weeks. In India though, there is no clearly defined age of viability, which used to be 28 weeks as per textbooks. It certainly cannot be earlier than 24 weeks, which is the standard for developed and high-resource western countries.

Hence, the practice followed here is to explain the parents, counsel them and take their consent to not resuscitate the non-viable foetus, which apparently was taken in this case.

We are in the realms of conjecture.

Assuming with all the latest technology at the disposal of the treating unit, such a premature foetus even if taken to viability in intensive care would probably suffer from neurological damage needing lifelong help, humongous cost not withstanding.

Also Read: Build trust and make hospitals great again

The Dilemma of Doctors

The bag in which the twins were wrapped.
The bag in which the twins were wrapped.
Photo: ANI
However, there has been a slip and that is of pronouncing a twitching baby as dead.

But from the facts above, it is clear that the doctors are functioning in a very difficult grey zone. And they really do not know what needs to be done in this grey zone of 22 to 24 weeks as there are no guidelines anywhere in the world regarding this.

If they choose to treat such foetuses aggressively, they would be accused of being greedy. If they discard them despite minimal signs of life, then they have declared a living being dead. Doctors face these dilemmas, on a daily basis because there are no guiding principles.

Handing the body over in polythene bags, appears to be insensitive on the part of the person concerned. Dignity of life should be maintained at all times.

But it would not be out of place to mention that Indian Academy of Pediatrics has published the comparative guidelines of American and European bodies on resuscitating in case of premature births. It states that in the preterm, foetuses are supposed to be resuscitated with the torso in the polythene bag (neck upwards outside) to avoid dissipation of heat and prevent hypothermia.

It is surprising that an FIR has been registered under Section 308 IPC within 24 hours, which encompasses ‘attempt to commit culpable homicide.’ Obviously no medical boards were set up and opinion taken before filing the FIR. Jacob Mathew Judgment of Supreme Court and guidelines issued in it were completely disregarded.

It is the over exposure of the public at large of an incident where the truth has been a casualty, which will result in doctors becoming overcautious even when declaring someone dead. Motives of greed would be attributed to the treating doctors and hospitals because of humongous cost involved, of the EEG, ECG, brain scan and other tests on all dead bodies – another potential and likely reason for violence and vandalism.

(Dr Ashwini Setya is a Gastroenterologist and Programme Director in Delhi’s Max Super Speciality Hospital. He can be reached at ashwini.setya@gmail.com. This is an opinion piece and the views expressed above are the author’s own. FIT neither endorses nor is responsible for the same. )

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