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Friday, December 30, 2005

200 Posts in CEmONC on contract basis

They are appointing these doctors to the GH and upgraded PHCs.

And the newspaper article does not mean "appointment of 200 doctors"

The news release is "creation of 200 posts" which is always going to be filled on contract basis like this

Now this merits some discussion.

Imagine there are 50 posts of doctors in a district. There were vacancies in some posts - few in districts like Chennai and Madurai and a lot of vacancies in districts like Nilgris and Perambalur.

Now the government appoints temporary doctors over there, on contract basis, (As per G.O No 197, H& FW Dept, dated 07.06.2004, Annexure IV paras 4, 5 and 6 where doctors are appointed on Contract Basis) with a condition that the contract shall initially be for six months from the date of appointment or till the regular candidates appointed through the TNPSC join duty at that place

1. The Appointee shall not be entitled for any preferential claim whatsoever for regular appointment in Government service at a future date.
2. The Appointee shall not be entitled to any probationary or other rights.
3. The services of the Appointee are liable to be terminated at any time during the contract period without any notice.

So this is a very good order (at least in theory). let me explain. Vacancies continue to arise in govt posting due to

1. Retirement
2. Creation of medical colleges , creation of departments
3. Few of our people "absconding" - either going abroad or settling down in a private practise - I think we have to blame our people for this.

But the TNPSC exam is conducted on a yearly basis. (some times once every 4 years). SO there are vacancies. The district collector and JD are given powers to appoint a temporary doctor so that the public do not suffer. Subham

But there are deeper meaning to it. If there is a vacancy, the govt can appoint a new doctor from the waiting list of previous TNPSC. So what the GO actually leads to is a situation where the govt pays Rs 8000 for the contract doctor, where as it has to pay Rs 15000 for a regular appointee.

In fact the appointment of contract doctors is for the sole reason of saving money. Any other reason (like administrative delay etc) can be easily solved with paper work.

When a regular doctor wishes to come to that place, the contract doctor can be asked to go home or move to another vacancy nearby

But now what has happened is CREATION OF POSTS. In short, these posts will be ALWAYS filled by doctors on contract basis only.

So why has it happened.

The reason is simple. There are many government medical colleges that have been started in the past few years. Thoothukudi, kanyakumari, Vellore, Theni etc. ANd that means you have to create posts in that college. As Dr.Asha has pointed out, such a post (in a teaching institution) cannot be on contract basis. So the government has decided to divert the Salary hitherto given to the staff (regular) in PHCs and GH and has decided to fill the post in GH and PHC on contract basis.

In short, you are getting (new) medical colleges (tertiary institutions) with regular staff while the (old) GH and PHC have contract staff. Some twenty years ago (when MCI was not so strict), they would have easily started a medical college with temporary staff.

And coming to the present order, that is of course a welcome step. When there is a CEmONC within 50 kilometres of any village in Tamil Nadu that is going to benefit the rural public.

In any government setup, It is a normal phenomenon to start something on a temporary basis and then move to permanent basis. So far everything is well and good. (That is appointment of doctors on temporary basis)

But what has now happened is the entire posts are temporary - that means there will always a contract doctor and not a regular doctor on that posts

So you have the following scenario

1. No CEmONC (Read Hospital)
2. CEmONC (Hospital) with temporary doctors at temporary posts
3. CEmONC (Hospital) with temporary doctors at regular posts
4. CEmONC (Hospital)with regular doctors at regular posts

Though 4 is the ideal scenario, you will agree that 2 is better than 1.

In the past the situation will proceed from 1 to 3 to 4
Now it has come from 1 to 2 and will NOT proceed.

And let me come to a user poll

What will you prefer

60 hospitals with temporary doctors
30 hosptials with permanent doctors.

Look it at a broader perspective... This question has two answers, one from a doctor point of view and another from a public point of view...

Monday, December 12, 2005

AlPG 2nd Councelling SC WP(Civil) No.157/2005 2005 12 06





AMIT GUPTA & ORS. Petitioner(s)


U.O.I. & ANR. Respondent(s)

(With appln(s) for stay)


Date: 06/12/2005 This Petition was called on for hearing today.





For Petitioner(s) Ms.Indu Malhotra, Adv.

Mr.Vikas Mehta,Adv.

For Respondent(s) Mr.Mohan Parasaran,A.S.G.

Ms.Sandhya Goswami, Adv.

For Ms. Sushma Suri ,Adv

Mr. Maninder Singh,Adv.

M/S K.L. Mehta & Co. ,Advs

UPON hearing counsel the Court made the following


List this matter in the 2nd week of January, 2006.

(G.V.Ramana) (Anand Singh)

Court Master Court Master

Monday, December 05, 2005

MAMS/MNAMS/Dip. N.B equal to MD/MS

No. V. 11025/6/94-MER (UG)
Government of India
Ministry of Health & Family Welfare
New Delhi, the 3.10.1994


Health Secretaries of all States/U.T. Govts.

Sub: NBE qualifications awarded by the National Board of Examination Equivalance of


I am directed to say that Medical qualification awarded by the National Board of Examinations are included in the First Schedule to the Indian Medical Council Act, 1956 and are considered at par with Post graduate Medical qualifications of the Indian Universities. However, it has been brought to our notice that employing organizations are not recognizing these degrees at par with MD/MS degrees of other Universities. As the National Board of Examinations, and autonomous body directly under the control of the central government, is keeping high standards of Medical examinations and it is requested that all concerned may please be instructed to give due importance to NBE qualifications and treat them at par with MD/MS of Indian Universities for all posts, including teaching posts.

The Medical Council of India while considering the question of equivalence of MAMS/MNAMS/Dip. N.B. qualification awarded by the National Board of Examination with M.D./M.S. and D.M./Mch. qualifications granted by Universities/Medical Institutions, has adopted the following recommendation, which was circulated to all the authorities concerned by the Council on 6.12.93 for–information and necessary guidance.

It is recommended that for teaching appointments in the broad specialities the holder of Diplomate NBE should have at least one year teaching experience as tutor/Registrar/Demonstrator or equivalent post in a recognized Medical College imparting undergraduate teaching and training for appointment as Lecturer. Regarding the candidates holding Diplomate NBE in Super Specialities, the training shall be for two years in a recognized Medical College having recognized postgraduate medical degree in the concerned speciality for appointment as Lecturer.

It is requested that the above may please be brought to the notice of all recruiting agencies under control for information and compliance.

Yours faithfully,
(Alok Perti)
Director (ME)

Friday, November 11, 2005

About Court Case in Karnataka

PG Aspirants: Fight for our righte - Merit Vs Might: "Post Graduate Aspirants Group: Karnataka State Junior Doctors' Association (KSJDA)

Other GO (Govt Orders) for CL (Casual Leave)

See Casual Leave as per FR (Fundamental Rules) for more information

1. Casual leave (CL) should not be combined with E.L.(Earned Leave) or U.E.L. (Unearned Leave)
2. Advance Application of CL need not contain the purpose for which the CL is required - G.O. Ms No 1410 P & AR dated 02.12.1977
3. Application for leave (or extension of leave) should be given either before availing the leave or at the time of joining duty - G.O. Ms No 1410 P & AR dated 02.12.1977
4. Employees irrespective of the office hours are eligible for 12 days CL - Govt Lr. No 109257- A/85 P & AR dated 31.12.1983
5. When CL is not available at the credit, they may take EL for short spells by sending advance intimation - Ruling (3) under FR 67
6. Contigent employees are also eligible for C.L if they have completed 30 days of duty - G.O. Ms No 1180 P & AR dated 15.12.1986

See Casual Leave as per FR (Fundamental Rules) for more information

Casual Leave as per FR (Fundamental Rules)

Other GO (Govt Orders) for CL (Casual Leave)
for more information

Executive Instructions regarding Casual Leave.
[See ruling (3) under Rule 85 of the Fundamental Rules of the Tamil Nadu Government
- Appendix I - Section VII.]
1. Casual leave is not provided for in the Fundamental Rules and is a concession to enable
Government servants in special circumstances to be absent from duty for short periods without such
absence being treated as leave under the Fundamental Rules or the Tamil Nadu Leave Rules, 1933.
2. No Government servant may, in any case, be absent on casual leave for more than @twelve
days in the course of one calendar year. Casual leave may be combined with compensatory leave,
Sundays, or other authorized holidays provided that the resulting period of absence from duty does
not exceed ten days. The fact that a maximum has been fixed for the amount of casual leave which
may be taken within a year, does not mean that an officer is entitled to take the full amount of casual
leave as a matter of course. †If the eleventh and subsequent days are incidentally declared as
holidays on account of natural calamities, death of national leaders, bandhs, strikes, a change in the
date of the festival as per the announcements made by religious heads during religious occasions,
etc., a Government servant who is on casual leave or compensatory leave may avail himself of those
days also eventhough the period of absence exceeds ten days.
@[G.O. Ms. No. 704, P. & A.R. (FR 3), Dept., dt 8-7-1985, w.e.f. 1-6-1985.]
†[G.O. Ms. No. 309, P. & A.R. (DO II) Dept., dt. 16-8-1993.]
Note (1).—In the case of Government servants appointed under emergency provision and who are
likely to be ousted at any time, their eligibility for casual leave shall be calculated with reference to the
period actually spent on duty and shall be Proportionately limited. As a working principle, they may be
granted two days casual leave for every two months service and such leave may be combined with
holidays subject to the maximum prescribed in the above instructions.
(G.O. Ms. No. 1122, Finance, dated 26th November 1959.)
Note (2).—Casual leave may be granted for half-a-day at a time on application. In such cases, the
half-a-day period should be either three hours from the commencement or before the closure of office
(G.O. Ms. No. 907, Finance, dated 21st July 1970.)
3. Heads of departments should intimate their intension or taking casual leave to Government in
the department concerned.
4. A register of casual leave taken should be maintained in every office.
5. Omitted.
6. Omitted.
[G.O. Ms. No. 802, P. & A.R. (FR. 3), Dept., dt. 14-8-85.]

Other GO (Govt Orders) for CL (Casual Leave)
for more information

St John’s Medical College to fill up mgmt seats

St John’s Medical College to fill up mgmt seats : by DH News Service Bangalore:

The Karnataka High Court on Thursday declared that Bangalore-based St John’s Medical College is free to fill up all the seats in the post-graduate medical courses under the management quota. This order, however, would be effective from the next academy year.

Meanwhile, the court granted relief to the students admitted to the college under the Government quota during the academic years 2004-05 and 2005-06 by not disturbing their admissions.

A division bench comprising Justice B Padmaraj and Justice V Jagannathan delivered the verdict on the petitions filed by the students and the college management.

Government quota : Students, admitted under the Government quota had questioned denial of admission by the college. On the other hand, the college, claiming autonomous status on being a minority institution, had questioned government’s power to allot students.

More students : By virtue of this judgement, the college, which has been permitted by the Medical Council of India to admit only 56 students for both the PG degree and diploma courses in an academic year, will have to accommodate 82 students. Both the MCI and the Rajiv Gandhi University of Health Sciences have to approve these admissions.

The college, contending that it had the right to fill up all the seats, had admitted 56 students during last two academic years. On the contrary, the Government had refused the contention of the college and had allotted 26 students in each academic year under its quota.

No power : While relaying upon the recent verdicts of the Apex Court, the division bench held that the Government can not force the college, which is a minority autonomous institution, to surrender 50 per cent of its seats to the Government’s seat sharing and reservation policies. “Forcing the institution for government quota in the form of any Act or the Rules or the regulations by the Medical Council of India would be violative of Article 30 of the Constitution”, the court held.

However, the bench said that the admissions already made under the Government quota can not be disturbed at this stage. The Court approved the admission of all 82 students saying that all of them were meritorious, selected as per the norms and admitted by virtue of various interim orders passed by the High Court and the Supreme Court. The Court also directed the college to allow all the students, who are pursuing various courses, to complete their courses.

College warned : Meanwhile, the division bench warned the college to be careful in future and always respect the law. The bench made this observation while dismissing a contempt of court petition filed by some of the students against Principal of the college for denying admissions to them despite interim orders of the court.

Wednesday, November 09, 2005

Ethical dilemmas.

Ethical dilemmas.

From Journal of Post Graduate Medicine

Pandya SK
Department of Neurosurgery, Seth GS Medical College, Parel, Bombay.

Correspondence Address:
Department of Neurosurgery, Seth GS Medical College, Parel, Bombay.

How to cite this article:
Pandya SK. Ethical dilemmas. J Postgrad Med 1997;43:1-3

How to cite this URL:
Pandya SK. Ethical dilemmas. J Postgrad Med [serial online] 1997 [cited 2005 Nov 9];43:1-3. Available from:;year=1997;volume=43;issue=1;spage=1;epage=3;aulast=Pandya

:: Introduction Top

Dilemma: difficulty, impasse, perplexity, predicament, quandary.
All medical doctors face situations from time to time, where the proper course of action is not clear. We are tempted, then, to paraphase Hamlet: “To do, or not to do - that is the question ...”

Take the case of a patient with confirmed malignant cancer of the breast whose chest x-ray film shows a rounded metastatic deposit. She now presents with a history of a recent focal epileptic fit but without any neurological abnormality on examination. Computerised tomographic scan shows what is most probably a metastasis in the left parietal lobe over the motor strip. Are we justified in advising excision of the tumour, knowing that it might leave her hemiplegic and when her general prognosis as regards long-term survival is grim?
Under such circumstances, how do we arrive at a decision? What do we navigate by?

:: Guiding principles Top

Four fundamental ethical principles have received universal acceptance by medical professionals:
* non-maleficence - ‘primum, non nocere’: first of all, do no harm
* beneficence - whatever we do must be for the benefit of the patient;
* respect for autonomy - the patient has an absolute right to make decisions concerning his own well-being, on any test or therapy proposed for him and on measures for resuscitation, prolonged maintenance on a ventilator and other such events.
In order to make such decisions, the patient - and family - need to be adequately informed on the pros and cons of each step. It is the communication of such details, in a manner that is clearly understood, that forms the basis of informed consent.
Justice as with reference to fair distribution of scarce resources; respect for the rights of the patient and family in the context of the rights of society at large; the use of the least expensive means in investigation and therapy; and respect for morally acceptable laws. It also implies the overcoming of personal prejudices - as against homosexuals or chronic alcoholics.
Thoughtful application of these principles to specific instances often helps resolve dilemmas.

:: Some common ethical dilemmas Top

Let us take examples from either end of the spectrum of life.
The treatment of infertility:
In a country where untold numbers of orphaned or discarded infants and children languish in unfeeling institutions where they are denied the attentions of parents and the company of siblings, is it fair for us to embark on such expensive techniques as in vitro fertilization?
On the other hand we have the plea of the barren wife who is willing to sacrifice almost everything to achieve the status of mother.
Possible resolution of dilemma:
Since it is the mother who comes to the doctor seeking treatment and since she has the right to decide on what should be done to and for her, the position of the orphaned children should not be allowed to intrude on the management of her problem.
Those in favour point to the legal sanction afforded to the termination of the life of the unborn foetus. Some have gone so far as to say that this is a welcome means for controlling our mushrooming population. Others have used it to get rid of female foetuses in their quest for the male child.
Many, however, remain troubled. Is this law morally acceptable? Are we ever justified in snuffing out life?
Possible resolution of dilemma:
This will depend on the beliefs and values cherished by the individual doctor. The doctor who holds life, as a sacred boon granted to an individual must refuse to perform or advice an abortion except in the specific instance where continuation of pregnancy may kill the mother. (Here, the operative principle is that the life of the mother is of greater concern than the life of the unborn foetus.)
Must we always strive to keep every baby alive, irrespective of costs?
Take two examples:
A premature newborn weighing 600 grams. Left to itself, it will perish. We can make extraordinary attempts to help it survive. In the process we may lead to a situation where the family is saddled with a severely handicapped individual with poor mental abilities.
A baby is born with meningomyelocele, paraplegia, incontinence of urine and severe hydrocephalus. A light applied to the head shows brilliant transillumination of the intracranial contents suggesting a paper-thin brain. It is possible to repair the skin over the exposed and damaged spinal cord and insert a shunt to drain the accumulated cerebrospinal fluid into the peritoneum. Survival is now assured but the family will bear the burden of looking after a mindless person who unknowingly passes urine and stools reflexly and will never understand, appreciate or communicate.
Possible resolution of dilemma:
The doctor must place the pros and cons of treatment in either instance before the parents. The doctor sympathetic to the social milieu in which the family exists and of the precarious economic circumstances of a particular family will emphasize the liabilities to the parents should treatment be preferred. I have, at times, gone a step further and told the parents that were the child in question mine, I would have decided against treatment.
If it is decided not to treat, should the patient’s life be terminated by a fatal dose of a drug? Some advocate stopping all feeds and supplying only water to take away thirst. The logic offered is that by this means we are not taking away life but allowing nature to take its own course. Is starvation to death not more cruel than instant death?
Possible resolution of dilemma:
Here, as often is the case with ethical dilemmas, the individual doctor’s conscience must dictate the course of action. Such a decision, however, must take into account the fact that the law of the land does not permit any doctor to kill the patient by any act of commission.
Admission to an intensive care unit:
The intensive care unit is already full of seriously ill patients, each of whom needs the special attention afforded in it. A fresh patient is brought to the clinic who also needs this specialized care. There is no other nearby centre that can take him. What is to be done?
Do we continue to treat existing patients and place this patient in a room or ward without special facilities for monitoring and treatment and, in the process, lose this patient? Do we shift the ‘least seriously ill patient’ out of the unit to make way for the new arrival and, in doing so, jeopardize the life of someone who may be on the way to recovery?
What if the new arrival is a ‘V.I.P.’?
A similar dilemma is posed when one has to select which of two patients is to be provided the only available ventilator.
Possible resolution of dilemma:
A new patient presenting to a clinic or hospital has not yet established the doctor-patient relationship with the consultant. Existing patients in the intensive care unit are already under his treatment and he is responsible for their welfare. His primary concern, then, must be for patients already in the unit. If, however, there if definite evidence that one of them can, without any risk, moved out of the intensive care unit to the half-way house of the semi-intensive care ward, such a transfer can be affected so as to take in the new patient.
Demand for euthanasia by a terminally ill patient in unremitting agony:
A patient with widespread cancer is in severe agony, which persists despite use of the maximal therapeutic doses of powerful drugs such as morphine. He begs to be relieved of pain and asks for the use of much larger doses, knowing that such doses will be fatal. Should one oblige?
Possible resolution of dilemma:
Here, as often is the case with ethical dilemmas, the individual doctor’s conscience must dictate the course of action. Such a decision, however, must take into account the fact that the law of the land does not permit any doctor to kill the patient by any act of commission.
Shutting off the ventilator:
The law, as it stands, does not allow one to take a brain-dead patient off the ventilator unless this patient is a donor of an organ such as the heart. What about the patient who is not suitable to offer an organ but whose relatives can no more afford the cost of an intensive care unit?
Should we insist on following the letter of the law so that we are not subject to prosecution under the Consumer Protection Act or the Indian Penal Code?
Possible resolution of dilemma:
The law, in this instance, is faulty. It is illogical to permit removal of the heart, lungs, kidneys, pancreas and other organs for transplantation into another patient and not allow switching off the ventilator. Senior lawyers consulted by us inform us that judges would, in all probability, rule in favour of the doctor, provided the procedure for the diagnosis of brain death before switching off the ventilator was foolproof.

:: Some personal guidelines Top

I have found the following additional guidelines useful. I pass them on for your consideration.
* The golden rule: Do unto others, as you would have others to do unto you. I have often found it helpful to ask myself, “Were I the patient, what course of action would I have wished the doctor to follow?”
* The patient comes first. The raison d’etre of our profession is the patient. We are here to serve him. The sick patient, often in physical pain and always in mental distress, deserves our fullest attention and calls for the best qualities of our mind and heart. His interests and decisions must prevail above all else except when the patient is non compos mentis. In the latter instance, the decisions of his family must prevail.
* The poor patient deserves special consideration He has nowhere else to go. He does not possess the means to command or demand. In our milieu he is often reduced to seeking help with bowed head and hands folded together. And he is ill. Medically malpractice against this group is particularly abhorrent.
* Ensure that your decisions and actions are scientific, humane, effective and in the best interests of the patient and his family. Record them. Once this is done, you need fear no individual, administrator or tribunal.

Ayurveda Drugs - Danger to Life - Poison which kills

The flip side of Ayurveda.

Thatte UM, Rege NN, Phatak SD, Dahanukar SA
Dept. of Pharmacology, Seth GS Medical College & KEM Hospital, Parel, Bombay, Maharashtra.

From Journal of Post Graduate Medicine

Correspondence Address:
Dept. of Pharmacology, Seth GS Medical College & KEM Hospital, Parel, Bombay, Maharashtra.

How to cite this article:
Thatte UM, Rege NN, Phatak SD, Dahanukar SA. The flip side of Ayurveda. J Postgrad Med 1993;39:179-82,182a

How to cite this URL:
Thatte UM, Rege NN, Phatak SD, Dahanukar SA. The flip side of Ayurveda. J Postgrad Med [serial online] 1993 [cited 2005 Nov 9];39:179-82,182a. Available from:;year=1993;volume=39;issue=4;spage=179;epage=82,182a;aulast=Thatte

"A 62 year old male patient was brought to the casualty in an unconscious state. A detailed history from relatives revealed that he was a known diabetic whose hyperglycemia was well controlled with insulin and glibenclamide. Five days earlier he had started an ayurvedic drug for psoriasis. He developed giddiness following ingestion of the drug, but ignored it. Subsequently, he became unconscious. He was diagnosed to be in hypoglycemic coma to which he ultimately succumbed."
While investigating the causes for such sudden hypoglycemia, the attending physician would naturally question, "Could the ayurvedic drug be responsible for the hypoglycemia?". This case was referred to the Adverse Reactions (Ayurvedic drugs) Monitoring Cell of the Ayurveda Research Centre of King Edward Memorial Hospital. On scanning available ayurvedic literature, no reference could be found describing metabolic actions of any of the constituents of this medication. Subsequent animal studies revealed, however, that in occasional mice a significant hypoglycemia occurred, reiterating the fact that the adverse interaction in the patient could have been due to the inadvertent co-administration of the ayurvedic agent and powerful hypoglycemic agents.
This case dramatically illustrates the sequel of self-administering 'ayurvedie' drugs and emphasises the fact that there is indeed a flip side to Ayurveda. We present in this brief article, the other side of Ayurveda.
A question that will arise at the outset is why read about adverse effects of ayurvedic drugs (let alone their uses or benefits) if we do not practice Ayurveda? The answer to this question is simple: over 80% of our population takes ayurvedic medicines - either self-prescribed or through a ‘Vaidya’. These same patients expect to be treated by our medicines while simultaneously taking ayurvedic medicines often leading to interactions of the type described above.
Another point to note is that a large number of herbal preparations are in the market under the label 1 ayurvedic Drugs'. Due to aggressive salesmanship and over-the-counter (OTC) availability, these drugs are prescribed by doctors and consumed by patients widely.
Hence, it is obvious, that at least in our country, we have to be aware of salient beneficial and adverse effects of commonly used ayurvedic drugs as much as of allopathic agents.
Ayurvedic drugs that one is likely to encounter in practice can be discussed under two broad categories: a) the traditional formulations including for example kadhas (decoctions), arishthas (decoctions containing alcohol) or gutis (pills) and b) the so called ayurvedic formulations which are a combination of different herbal extracts (sometimes aqueous, sometimes alcoholic). These plants are prescribed individually or together for a particular condition in ayurvedic texts. However, their fixed dose combination, as marketed, may not be mentioned therein. These herbal medicines are prescribed for a wide variety of non-specific conditions like improving vitality, anti-stress effects, boosting immunity and increasing appetite or memory!
Since, in this article we are discussing adverse reactions, we shall for the moment assume efficacy of these herbal preparations. It is an old adage of pharmacology that teaches us that if a drug is effective it is most likely to produce a side effect [1].
In fact, standard text-books of Ayurveda mention that ayurvedic drugs, if improperly used can be toxic. Charaka[2] states in the Sutrasthana of the Charaka Sarnhita - "A potent poison also becomes the best drug on proper administration. On the contrary, even the best drug becomes a potent poison if used badly".
Ayurvedic texts classify toxic plants (See into different categories depending on the part of the plant that is toxic. Subsequent research has revealed the exact chemical nature of the toxic alkaloid validating the knowledge laid down in ayurvedic texts.

In fact, in Ayurveda, there is a separate science which deals with toxicological aspects and is known as Vishagarvajrodhika tantra' (toxicology)[3].
There are enough grounds to conjecture that some knowledge regarding toxicity of plants was obtained through observation of behaviour of insects and animals towards these plants. Plants, which were never infested with insects, were considered dangerous: these were later shown to contain repellants like anthraquinone, naphthalene or nimbidine. Plants like vinca or nerium from which animals steer clear have later been shown to contain toxic materials. Aconitum does not allow any other plant in its vicinity! An interesting feature about ancient ayurvedic physicians worth noting, and perhaps emulating, is their ability to improvise on information they had, using whatever facilities were at hand. Thus, for example, when the physicians discovered that a particular plant was visciously toxic and perhaps fatal, they evolved ways by which the toxic components could be destroyed and converted them not only to safe but further therapeutically useful entities! The story of Aconitum heterophyllum is illustrative in this respect. The roots of this plant are considered toxic (they contain an alkaloid aconitine) and following ingestion of roots, the toxicity manifests in the form of tingling numbness of mouth and throat, abdominal pain, loss of muscle power, visual and auditory disturbances and finally clonic convulsions [4]. However, aconite forms an important constituent of ayurvedic formulations. The aconite used in the formulations is not a crude agent but one, which is processed. This processing involves boiling of roots with 2 parts of cow's urine (7 hours per day) for 2 consecutive days. The roots are then thoroughly washed with water and boiled with 2 parts of cow's milk for the same duration. These are washed again with lukewarm water, cut into pieces, dried and ground. It has been shown that aconite becomes safe only after this elaborate process and all the steps are 6 essential for complete detoxification[6],[7].
Besides toxicology, ayurvedic pharmacology describes in some detail the side effects that can occur with different therapeutically useful drugs. Further, it also describes ways (which also include manufacturing techniques) to minimise these side effects. Just like we, for example, would advise that NSAIDs should not be taken on an empty stomach, Ayurveda gives instructions regarding time of drug administration, the relationship with food, type of food which should be avoided/permitted with the drug etc. The do's and don'ts are clearly enunciated. For example, amalki (amla, Emblica officinalis) should be avoided at bedtime to prevent harmful effects on teeth [8]. Chyavanprash contains large quantities of Amla - one wonders whether the package insert with any Chyavanprash mentions this precaution! Similarly, pippali (Piper longum) used in asthma should be avoided in patients with peptic ulcer disease and should be consumed with milk [9].
Tribhuvankirti is a combination of several plants which is very commonly used to treat a "cold in the head" and fever. There are clear instructions in Ayurveda that because it contains aconite [Table - 1] it should be used cautiously. When used, it should be taken with tulsi (holy basil) juice, ginger juice or honey[8].
Guggul is derived from the resin of Commiphora mukul [11] and is used in a variety of diseases including hypercholestrolemia (in fact gugglulip has been introduced into the market for this condition) and arthritis[12]. Ayurveda specifies that guggul should be used cautiously in patients with peptic ulcer disease. While on guggul therapy the patient is advised to avoid sour food, alcohol and heavy exercise[13],[14].
The subject of teratogenecity also figures in Ayurveda. Thus, certain plants like Terminalia hebula (harda) are to be avoided in pregnancy. This is a constituent of a large number of OTC preparations. It is a powerful purgative and is supposed to stimulate GI motility and would therefore be contraindicated in pregnancy[15]! This fact is not sufficiently publicised.
Apart from plants, Ayurveda also includes metals in its formulary. Thus, several preparations containing metals like mercury, lead and copper are available readily in the market on OTC basis. These metals have to be deligently processed before they are suitable for human consumption and there is again a long list of do's and don'ts regarding their use. Unfortunately, there are no quality control methods to standardise such metal containing drugs and to find out whether processing of metal is done appropriately so as to render it nontoxic. This thus increases the probability of toxic effects.
The case history of a 70-year-old male patient referred to the ADR monitoring cell illustrates the relevance of being aware of these. This patient was taking a 'herbo-mineral' preparation 'Mahayograj Guggul' in the dose of 4 tablets three times a day, for the complaints of joint pains for well over two years. He got relief from the arthritis but developed symptoms of lead poisioning including severe anaemia with classic basophilic stippling of the RBCs. The case was referred to the ADR cell with the query whether Mahayograj Guggul could lead to this problem. As this preparation contains lead, our centre adviced immediate withdrawal of the preparation.
This particular preparation is prescribed for rheumatoid arthritis in ayurvedic texts[13] and contains several plants and metals as shown in .

Ayurvedic textbooks recommend a special pharmaceutical process to detoxify the metals. The lead in this preparation has to be processed by first heating over a fire till it glows. It should then be cooled by dipping into a mixture of sesame oil, buttermilk, cow's urine and a decoction of three plants, viz. amia (E.officinalis), beheda (T. bellerica) and harda (T. chebula). After repeating this procedure thrice, the lead is heated the fourth time following which it is dipped into a churna (powder) made of the rind of tamarind and Piper longum. This lead is then mixed with arsenic sulphide and wrapped in a betel leaf and warmed in a crucible to a fixed temperature. This process is repeated thirty times before nagabhasma or processed lead is ready for use[16]. In addition, in the doses that this patient was taking the drug he would have consumed a phenomenal 414 mg lead per day for more than 2 years leading to lead toxicity. There are two points to note in this case. Firstly, Ayurveda definitely reconimends Mahayogiraj Guggul for rheumatoid arthritis but has cautioned about duration of therapy, which was overlooked. Secondly, as there are no quality control procedures in existence, there is rio way to know whether the lead in this formulation had been processed in the complex way it should have been.
This brings us to the second group of the 'herbal' formulations marketed under the label 'Ayurvedic'. All doctors are aware that such preparations are available, many may be prescribing them and some will come across patients self-medicating themselves with these drugs. What exactly are these drugs and what do we know about them? Most doctors prescribe these agents, in spite of lack of sufficient clinical studies (using the randomised controlled clinical trial model) proving their efficacy in comparison to allopathic drugs, in the utopian misconception that "never mind if they are ineffective, they will be safe!"
What adverse effects can occur with such formulations? The most glaring are possible drug interactions with the usually co-administered allopathic drugs. Several plants have been shown to alter bio-availability of allopathic drugs[17].
Similarly when used in combination with allopathic drugs they may alter their pharmacodynamics. The example in the diabetic patient described earlier is illustrative. Further, such herbal preparations may produce toxicity, often unexpectedly, per se.
A very herbal remedy is the need to conduct safety studies on them. Protagonists for this believe that with the changing ecological environment, use of pesticides, new manufacturing techniques, modern formulations and combinations of herbs not prescribed in ayurvedic texts, the need for looking at ayurvedic herbal drugs as new drug entities cannot be ignored. This is being seriously considered by the office of the Drugs Controller of India and an amendment to the laws governing manufacture and sale of ayurvedic drugs is on the anvil.
Opponents feel however that herbal remedies are natural remedies and are beyond conventional toxicity studies. Further developmental costs would be formidable.
Is there a via media? Perhaps incorporation of any or all of the methods summarised in [Table:3] would optimise use of ayurvedic drugs.
The Adverse Drug Reaction monitoring cell for Ayurvedic Drugs has been set up at the Ayurveda Research Centre of King Edward Memorial Hospital, Mumbai with several aims. Alongwith documenting anecdotal case reports suggestive of adverse effects to ayurvedic drugs, (please see ADR reporting card) we also, where necessary conduct studies in animals to confirm or rule out the cause and effect relation between the drugs and side effects reported. Further we give information related to ayurvedic drugs.
In conclusion we can reiterate that in view of the fact that we are
a) not using ayurvedic drugs only in the form as described in standard texts,
b) making over-the-counter formulations without much heed to the need for individualisation,
c) giving ayurvedic drugs in combination with allopathic agents which have a narrow therapeutic margin,
d) using raw plant material that is possibly polluted by environmental and ecological devastation,
e) not having good quality control methodologies,
We must beware. We must not wait for a thalidomide- like tragedy in Ayurveda to shake us out of our complacence that ayurvedic drugs are safe!

:: References Top

1. Melmon KL, Morrelli HE. Drug Reactions. In: Clinical Pharmacology. Basic Principles in Therapeutics, 2nd ed. New York: Macrinillan Publ Co; 1978, pp 968. Back to cited text no. 1
2. Samhita C. Sutrasthanam In: Sharma PV, editor. Charak Samhita Varanasi: Chaukhamba Orientalia; 985; 1:126. Back to cited text no. 2
3. Dahanulkar SA, Thatte UM. Historical survey of the evolution of Ayurveda. In: Ayurveda Revisited. Mumbai: Popular Prakashana; 1989; 10-27. Back to cited text no. 3
4. Franklin CA, In: Modi's Medical Junspiudence and Toxicology, 21st ed. Mumbai: NM Tripathi Pvt. Ltd; 1988, pp 279. Back to cited text no. 4
5. Sastri A. In: Sri Vagbhatacharya’s Rasaratna Samuchchaya, 6th ed. Varansi: Chawkhamba Sanskrit Series office; 1978, pp 590. Back to cited text no. 5
6. Sen SP, Khosla RL. Effect of Sodhana on the toxicity of aconite (vatsnava). Current Med Pract 1968; 12:694. Back to cited text no. 6
7. Thorat S, Dahanulkar SA. Can we dispense with ayurvedic Somskaras? J Postgrad Med 1991; 37:157-159. Back to cited text no. 7
8. Gogate VM. Emblica officinalis. In: Drvyaguna Vigyan. 1st ed. Pune: Continental Prakashan; 1962, pp 350. Back to cited text no. 8
9. Swami B. Tribhuvankirti. In: Rasadarpan - part 1, 3rd ed. Patiyala: Swami Publication; 985, pp 393. Back to cited text no. 9
10. Sukh Dev. A modern look at an age old ayurvedic drug gugguiu. Science Age 5:13-18. Back to cited text no. 10
11. Satyavati GV. Gum guggul (Commiphora mukul) - the success story of an ancient insight leading to a modern discovery. Ind J Med Res 1988; 87:327-335. Back to cited text no. 11
12. Gogate VM. In: ayurvedic Materia Medica. Pune: Continental Prakashan; 1981, pp 289-290. Back to cited text no. 12
13. In: Bhavaprakash Nighantu Karpooradi vargu. Varanasi: Chaulkhamba Sanskrit Samsthan; 1969, pp 205. Back to cited text no. 13
14. Gogate VM. Terminalia chebula. In: Dravyaguna Vigyan, 1st ed. Pune: Continental Prakashan; 1982, pp 436 Back to cited text no. 14
15. Gune G. In: Ayurvediya Aushadhi Gunadharma Shastra, Siddhaushadhi, part IV, 2nd ed. Ahmadnagar: Mohan Mandir; 1934; 8-9. Back to cited text no. 15
16. Dahanulkar SA, Kapadia AB, Karandikar SM. Influence of trikatu on rifampicin bioavailability. Indian Drugs 1982; 271-273. Back to cited text no. 16
17. Back to cited text no. 17

Doctor bashing and why the Indian medical profession must evolve.

Doctor bashing and why the Indian medical profession must evolve.

Gandhi JS

From Journal of Post Graduate Medicine

How to cite this article:
Gandhi JS. Doctor bashing and why the Indian medical profession must evolve. J Postgrad Med 2002;48:155-155

How to cite this URL:
Gandhi JS. Doctor bashing and why the Indian medical profession must evolve. J Postgrad Med [serial online] 2002 [cited 2005 Nov 9];48:155-155. Available from:;year=2002;volume=48;issue=2;spage=155;epage=155;aulast=Gandhi

I read with interest the comments by Dr. Pandya on the harassment and violence inflicted on doctors in India.[1] Indeed, in one of the recent issues of the British Medical Journal a Pakistani doctor reports similar events in his country.[2] It is clear even in Britain that doctors no longer have the kudos that their predecessors commanded implicitly as part of their professional role. Certainly in the UK this loss of faith in the medical profession has resulted from large malpractice scandals incriminating senior doctors during the last decade. We saw over the nineties the Bristol paediatric cardiac surgery scandal, the Alder Hey revelations, the Dr Shipman affair, and an array of ignominious ends to otherwise admirable careers. It was undoubtedly the case in these instances that patient care had been substandard. The General Medical Council responded briskly by establishing new mechanisms to monitor the performance of consultants (who hitherto had worked with relative impunity) and by forming bodies such as the National Institute of Clinical Excellence to audit clinical practices. The British people also changed their view of doctors, and there is presently a rising trend of complaints against health professionals and the system of the National Health Service (NHS). For the time being in Britain we are only more aware of the medicolegal aspects of our practice (so that clinical care is improving), but it may be that soon we will work in the litigious culture found in North America.
The spate of aggression against doctors in the subcontinent must also prompt a timely reassessment of the doctor’s role in Indian society. As observed by Dr Pandya and others, frequently the anger and distrust expressed by patients and relatives against doctors stem from poor communication rather than negligence. Patients and relatives feel alienated and powerless. In Indopakistani culture, anger can easily be vented in a fanatic manner that involves injury or murder, and it seems that the current vogue is to channel this destructive force towards the medical profession. Although I suspect there may be political issues that have led to the persecution of individual Indian doctors, surely it is now up to the Indian profession as a whole to actively redeem itself in the eyes of the public. Unlike in Britain, the Indian state is unlikely to show interest in the plight of its doctors, and changes to improve patient care and restore public confidence must arise from within the profession.
As a symbolic step, undergraduate curricula in India must now include teaching on communication between doctor and patient in earnest. On speaking to doctors who have qualified in India and now work in the NHS, the recurrent opinion I encounter is that there is a gross lack of such training. Moreover, the importance of good communication needs to be reiterated throughout postgraduate training. Indian doctors must also now be provoked to create a system to handle complaints from patients and relatives that gives people dignity, and minimises the dishonesty and inefficiency that Indians themselves admit riddles their existing institutions. Control of the quality of patient care is warranted especially in India, where healthcare is primarily in the private sector and patients are potentially vulnerable to serious iatrogenic blunders. Cynics will quickly say that the corruption cannot be erased, but surely every effort will help in reducing the actual burden of dishonesty that is sparking frustration and violence. If there is no accountability or audit in the profession, then barbarism will persist and probably worsen. The minutiae of how such a system of audit can be conceived, formed, financed, and run is not a matter for a bystander such as myself to contemplate. And armchair analyses and cynicism will not suffice, because if the chair is kept too warm too long Indian doctors will inevitably attain the status given to unreliable politicians.

:: References

1. Pandya SK. Doctor patient relationships: The importance of the patient’s perceptions. J Postgrad Med 2001;47:3-7. Back to cited text no. 1
2. Shafqat S. New hazard of medicine. BMJ 2002;324:1045. Back to cited text no. 2

Saturday, November 05, 2005

Compensatory Leave

To have a comprehensive Idea about COL (Compensatory Leave, please refer Revenue dept - District Office Manual - 1973 - Vol I - Page 150 Para 169)

The question asked

MessageDate : 11/11/2005 12:09:32 AM
Posted By : vijay
Email :
Message : PLEASE DISREGARD EARLIER MESSAGE DUE TO AN ERROR...........Sir, Thanks for your kind reply. ……. I request your further clarification in this issue. An example: A person has credit of 2 days COL on 31.10.2005 for his attendance during govt. holiday on 02.10.2005 and 11.10.2005 ……. QUESTION NO. 1. In this situation, whether he can carry those 2 days COL till 01.04.2006 (i.e. six months from the date first worked) or whether those COL expires on 31.12.2005 (calendar year effect)…..QUESTION NO. 2: Whether any restrictions such that only 10 days COL can be availed during the period from 1.6. 2005 to 31.12.2005 (i.e. in half of a calendar year, maximum 10 days COL can be availed)…..…..QUESTION NO.3: Whether COL can be availed for Second Saturday, if worked? Your kind advise is appreciated.......thanks.

One of our replies

Please see

2.The question of calendar year does not arise since eligibility of compensatory leave(Col) is six months from the date of such holiday work.

That answers your first question --> He can carry that COL till 01.04.2004 (or may be 31/03/2005 !!!!)

Coming to your second question,

NO restrictions.... For a person whose probation has been declared and service regularised , you can take a maximum of 10 days continous CL, COL, PL, W/o, Govt Holiday . YOu cannot take CL, COL etc for more than 10 continous days. However there is an exception if the 11th day is UNEXPECTEDLY declared an holiday (say floods along cauvery etc) as per G.O No 309, P & AR dated 16.8.93

Coming to your thrid question,

Yes... As per the following rule

1. Revenue dept - District Office Manual - 1973 - Vol I - Page 150 Para 169

2. G.O. Ms No 2218 (Misc) dated 14.12.81

3. Govt. Lr. No 16215/83-1/P & A.R. dated 27.04.83

4. Govt Lr. No 10 P & AR dept dated 28.11.2000


Subject : RE: C.O.L.
MessageDate : 11/10/2005 1:22:08 PM
Posted By :
Email :
Message : Dear Mr.Vijay,

1.Maximum compensation leave allowed in 20 days in a calendar year. Total availing of compensation Leave(COL) should not exceed 10 days at a time.

2.The question of calendar year does not arise since eligibility of compensatory leave(Col) is six months from the date of such holiday work.


Sir, as far as I know, compensatory leave (COL) could be accumulated for six months from the date of work but total leave shouldn't exceed 20 days on credit at any time. Am I correct? NOW THE QUESTION IS: Whether COL on credit ( days) get lapsed at the end of December 31st or could be carried over for the next calander year with the main restrictions of 6 months from the date worked. In nutshell, whether calander year do any restrictions/nullifying the credit of COL? Request your advise.

MessageDate : 11/5/2005 6:02:55 PM
Posted By : doctor
Email :
Message : dear vijay .you are right .

1.compensatory off leavecan be carried over to the next calender year unlike casual leave which will lapse at the end of december 31st.
2.comp leave can be combined with c.l.but not with a week off either before or after a comp .leave.
3.casual leave can be combined with a week off before or after.
4.the total comp.leave and permission leave availed by an individual should not exceed 20 in a single year. credit a govt holiday for comp.leave the individual must work full time.8am to 5 pm at phc
6.if the govt holiday is not credited for cop.lave then 1/2 day duty is enough for that day .that is 8am to 1pm enough at phc if u dont credit the govt holiday for comp.leave

Sir, as far as I know, compensatory leave (COL) could be accumulated for six months from the date of work but total leave shouldn't exceed 20 days on credit at any time. Am I correct? NOW THE QUESTION IS: Whether COL on credit ( days) get lapsed at the end of December 31st or could be carried over for the next calander year with the main restrictions of 6 months from the date worked. In nutshell, whether calander year do any restrictions/nullifying the credit of COL? Request your advise.

Friday, November 04, 2005

Civil Surgeon

For your information, the following are earlier replies of DMS in the bulletin board, which may be useful to you

  • Civil Surgeon - Dr.Sankararaman CML no. 5050 of 2002: CML no. 4084 of 2005,
  • Senior Civil Surgeon-Dr.A.A.Sami CML no. 3175 of 2002: CML no. 2299 of 2005, and
  • Sr.Asst.Surgeon 6708/2002 is the last CML Numbers declared as promotion in the respective category.
Approximately for 225 Senior Assistant Surgeons promotion will be given.
Presently preparation of promotion list for Sr.Civil Surgeon, Civil Surgeon and Sr.Asst.Surgeon are in progress at DMS as per their intimation. So, keep your finger crossed for your promotions.
  • Sr.Civil Surgeon (general) promotion comes after 22 years,
  • Civil Surgeons after 17 years,
  • Sr.Asst.Surgeon after 15 years.
There were heavy recruitment during the year 1990 to 1991 amounts to approximately 1800 doctors (due 10A1 etc). Due to which 1990 batch onwards promotion chances will be in slower path. If you have any doubt, quote your CML No. and confirm the promotion opportunity with DMS. ( On completion of 10 years service, u will get Slection.Grade Asst which is the earliest promotion a Asst.Surgeon can expect than the Sr.Asst.Surgeon) Anyway wish you good luck for early promotions.

Tuesday, October 25, 2005

Doctors want TNPSC exam cancelled

Doctors want TNPSC exam cancelled - Their applications for the posts of assistant surgeon were rejected
by Special Correspondent of the Hindu at

CHENNAI: Ten doctors excluded from the selection process for appointment to 1,825 posts of assistant surgeon have moved the Madras High Court seeking cancellation of the October 16 examination conducted by the Tamil Nadu Public Service Commission (TNPSC).

In the alternative, the petitioner-doctors have prayed for holding a supplementary examination for about 2,400 eligible doctors, including themselves, whose applications were rejected by the TNPSC on the ground that they had not filled certain columns and did not sign the mandatory declaration. As an interim relief, they sought to restrain the TNPSC from publishing the results of the October 16 examination.

Justice A. Kulasekaran, before whom the joint petition by doctors M. Satish Manoharan, D. Geethapriya and others came up for hearing ordered notice to the TNPSC and posted the matter to October 27 for hearing.

Maintaining that they did not fill up some columns in the application because they came under the `For Office Use Only" category, the petitioners said, "the application format created confusion in the minds of candidates."

They added that it was not a serious omission warranting rejection of application at the initial itself. As the applications were submitted by August 4, the authorities had sufficient time to call upon the applicants to rectify the mistake. By choosing to reject the applications summarily, the authorities "deprived the petitioners of their valuable right to get into Government services."

Of 1,825 posts, 530 are for speciality services.

Despite several requests, the petitioners and other similarly placed doctors were not permitted to verify the reason given by the TNPSC, the petition said.

Monday, October 24, 2005

Fraud Ayurveda Doctor to be arrested

by Express News Service
==Thane police close in on ‘cancer cure’ doctor==
Mumbai, October 24:
HE HAD challenged a Bombay High Court order cancelling his anticipatory bail. Now, with the Supreme Court dismissing his special leave petition, Ramesh Dhokte’s arrest seems inevitable.

But the ayurvedic doctor from Dombivli, who made a lot of money by selling his cancer cure to gullible patients, has admitted himself to Hinduja Hospital, Mahim, for a hand injury.

‘‘We have informed the hospital in writing about the arrest warrant issued by the Kalyan court,’’ said

Police Sub-Inspector Sanju John of the Thane Crime Branch. ‘‘We told them to inform us before discharging him.’’

It’s not the first time Dhokte—the Supreme Court dismissed his plea on October 21—has got himself admitted while facing impending arrest.

In December 2003, when the Maharashtra Council of Indian Medicine lodged a case against him for making false ‘cancer cure’ claims, he had got admitted to Hinduja Hospital.

On September 26, the Bombay High Court cancelled his bail for creating hurdles in the case and tampering with evidence.

The order had observed: ‘‘It is seen that Dhokte is making use of false claims and false certificates to support his claim that he is able to cure cancer patients with ‘herbs’.’’

Unravelling the case
December 2003:
The Maharashtra Council of Indian Medicine lodges a complaint against Dhokte for making false claims of curing cancer with herbs

Case is transferred to the Thane Economic Offences Wing
January 2004:
Dhokte gets anticipatory bail from Thane Sessions Court
March 2004:
Dr Prakash Deshmukh, an MCIM member who was part of the inquiry committee probing Dhokte, files a defamation case against the ayurvedic doctor for ‘feeding’ baseless and libelous reports in a regional newspaper
December 2004:
Food and Drugs Administration files a case against Dhokte for producing and selling drugs without approval and for selling illegal drugs using fake licence numbers
September 2005:
Bombay High Court sets aside anticipatory bail order issued by lower court
October 2005:
Kalyan court issues arrest warrant; Dhokte’s petition challenging high court order is dismissed in Supreme Court

Thursday, October 20, 2005

Petition to quash TNPSC exam admitted

Thursday October 20, 09:08 PM
Petition to quash TNPSC exam admitted
By ChennaiOnline News Service

Madurai, Oct 20 (Chennaionline): The Madurai Bench of the Madras High Court today admitted a writ petition seeking to quash the examination conducted by the Tamil Nadu Public Service Commission (TNPSC) for the recruitment of assistant surgeons held on October 16.

Justice D Murugesan issued notice to the Deputy Secretary of the TNPSC and the Director of Public Health.

Referring to the prayer of the petitioner Dr M Manimozhi that the court should grant an interim injunction restraining the TNPSC from publishing the results, the judge asked the government pleader to get the government''s view and posted the case for October 27.

The petitioner submitted that she had applied for the examination conducted to recruit 1,825 assistant surgeons (1,295 general and 530 speciality) before the due date of August4.

However, the application for direct recruitment was rejected because she had not produced both particulars and declarations. Later, when she visited the TNPSC office and submitted the particulars required by them, she was told that she would get the hall ticket. However, she did not get the same.

She said if she had not submitted the particulars, the same could be obtained at anytime of the recruitment.

She also pointed out that TNPSC had rejected 2,500 applications out of the total 6,500 applications on flimsy grounds. However, some candidates had approached the High Court which directed the TNPSC to permit them to write the examination. (Agencies)

Friday, October 14, 2005

High Court Madras nod for doctors to take TNPSC exam

The Madras High Court has ordered Tamilnadu Public Service Commission (TNPSC) to permit over 100 doctors to take the examination for the post of government assistant medical officers whose application had been dismissed by the TNPSC.

It may be noted that TNPSC had issued a notice to fill up 1,295 vacant assistant medical officers' posts last July. Thousands of applications were received of which over 100 applications were dismissed as they were not properly filled in.

Opposing this, over 100 doctors filed a petition in the High Court. Hearing their appeal, Justice C Nagappan ordered the TNPSC to let those doctors write the examination which is slated to be held on 14 October.

Friday, September 30, 2005

AlPG 2nd Councelling SC WP(Civil) No.157/2005 2005 09 30





AMIT GUPTA & ORS. Petitioner(s)


U.O.I. & ANR. Respondent(s)

(With appln(s) for stay and impleadment as party respondent)


Date: 30/09/2005 This Petition was called on for hearing today.





For Petitioner(s) Ms. Indu Malhotra, Adv.

MR. Vikas Mehta, Adv.

Mr. Vikaram Mehta, Adv.

For Respondent(s) Mr. Maninder Singh, Adv.

Ms. Pratibha M. Singh, Adv.

Mr. Sunil Fernandes, Adv.

Mr. Saurabh Mishra, Adv.

Mr. Dhruv Mehta, Adv.

Mr. Marsh Vardhan Jha, Adv.

Mr. Yesh Raj Singh Deora, Adv.

for M/S K.L. Mehta & Co., Advs.

Mr. Mohan Parasaran, A.S.G.

Ms. Sandhya Goswami, Adv.

Mrs. Sunita Sharma, Adv.

Ms. Sushma Suri, Adv,

Mr. R.K. Adsure, Adv.

UPON hearing counsel the Court made the following


It is represented that the modalities for second round of counselling for All

India Quota of Postgraduate Courses are being discussed between the Ministry and the

Medical Council of India. The Ministry and/or the Medical Council of India shall

finalize the same within four weeks and file an affidavit placing on record the result of

such discussions.

List the petition towards the end of November, 2005.

(N. Annapurna) (V.P. Tyagi)

Court Master Court Master

Sunday, September 04, 2005

Supreme Court judgement on sterilisations

Supreme Court judgement on sterilisations
Mohan Rao


A recently reported Supreme Court of India order (1) has far-reaching implications for one of India's largest public health programmes. In response to a Public Interest Litigation, the Court noted: "For the time being, no doctor without gynaecological training for at least five years' post degree experience should be permitted to carry out the sterilisation programme." A three-judge Bench also instructed state governments to pay a compensation of Rs one lakh per patient dying due to sterilisation. Further, noting that there were no uniform guidelines for the conduct of these operations, the Court also ordered that the Centre should lay down such guidelines within four weeks.
Given that critics of the family planning programme have frequently drawn attention to the appalling conditions under which target-driven sterilisations are conducted in the country, this judgement can only be welcomed. At the same time, it draws attention to several other issues that equally need consideration.
Sterilisations, whether male or female, are among the safest of surgeries. But they carry, in our country, the burden of the largest mortality toll ever imposed by a welfare programme in the history of the world. During the years of the Emergency official sources admit the death of 1,740 persons, predominantly male (2). These were largely poor people, drawn to undergo sterilisations by the 'compensations' offered, or coerced into undergoing sterilisations. They were disproportionately from among the marginalised and minorities which meant that that the issue did not receive the attention it deserved. But as male sterilisations proved politically costly attention turned to female sterilisations, often in camps, something evocatively described in Deepa Dhanraj's powerful documentary on the family planning programme, Something Like a War.
Despite being a signatory to the International Conference on Population and Development, despite the fact that the National Population Policy (NPP) explicitly renounces targets and emphasises issues of quality of care, it is no secret that states were scarcely influenced by the 'paradigm shift' that the NPP is said to have brought about. This shift emphasised the need to meet unmet needs for health services, including reproductive health services (3).
That there continues to be a single-minded focus on numbers is indisputable. Several state population policies link health personnel's performance assessments with family planning target achievements. Family planning performance has also been made a condition for the release of development funds in a range of schemes. A two-child norm has been implemented for contestants to the Panchayat Raj institution elections in several states. This mocks efforts to bring the deprived populations into the political mainstream at the grass roots level, since these population policies take away from dalits, adivasis, women and the poor in general the political space that the 74th Amendment sought to provide. Studies have shown that this has led to women being forced to seek sex-selective abortions followed by sterilisations (4). Ironically, the Supreme Court, in another judgment, upheld this two-child norm (5).
Over the same period, there has been a state-led collapse of the under-funded public health system. The National Health Policy (NHP) admits that India has the dubious distinction - at 0.9 per cent of the Gross Domestic Product - of the fifth lowest public health spending in the world, lower even than countries of Sub Saharan Africa (6). It is no surprise then that we continue to have the largest morbidity and mortality load among countries with similar per capita incomes. The collapse of the public health system has meant that more and more people are driven into the private sector. And thus, again as the NHP admits, medical expenditure has emerged as one of the leading causes of indebtedness. Indeed, the NHP also notes that poor families typically reduce even their basic nutritional requirements to meet their medical expenses.
It is these two factors above all - the collapse of the public health system and the single-minded focus on target achievements in family planning - that lead to sterilisations under unhygienic conditions, with little care to screen prospective patients, or to provide some semblance of quality of operative procedures. Sterilisations are also performed with poor equipment, and the system has no use for follow-up (7). To focus on the training of doctors alone is therefore to miss the woods for the trees. Is there not an urgent need to address the overall conditions and context in which such procedures are performed?
Must matters of quality of care be decided by the Supreme Court? Why is the Indian Medical Association silent? The Department of Health and Family Welfare drafted standard guidelines for quality of care for sterilisations years ago. Of course in their quest for targets, states are not following these guidelines.
There are other concerns raised by the Supreme Court order that need debate. There is an acute shortage of doctors in the public health system. MBBS trained doctors are perfectly capable of carrying out sterilisations. But if a specialist is now required, does this mean the public health system ceases offering these facilities? Would this then not mean that more patients are pushed into the exploitative arms of the private sector?
It is presumed that quality of care can be guaranteed by specialisation. Specialised obstetricians and gynaecologists in the private sector perform significantly more - and most often unnecessary - Caesaerean sections (8). We only have to remember the silence of the Federation of Obstetricians and Gynaecological Societies of India on sex-selective abortions - to which they contribute disproportionately - to realise that this faith in specialisation may be misplaced.
Reports are legion about poor patients being rendered blind following operations for cataract. Will this too have to be attended to by the Supreme Court? In short, what are the implications for other procedures, from Caesarean sections to coronary by-pass surgery, carried out by the public health system in India? Will norms for training be laid out for all of them? Will these norms apply to the private sector in medical care, the largest and least regulated in the world?
Further, what are the financial implications of the order for the public health system, ailing for lack of funds? In the early 1960s the issue of quality of care hindered the development of the primary health care system in the country. It is also frequently raised to open up Indian markets for multinational companies that equate quality of care with high-tech care.
It is widely accepted that the problems with health care in India are systemic in nature; the solutions too must take a systemic view.

1. Anonymous. Only experienced doctors to sterilise: SC. Press Trust of India. New Delhi, March 6, 2005.
2. Government of India, Ministry of Home Affairs. Report of the Shah Commission of Enquiry, Vol.3. New Delhi: GOI Press; 1978.
3. Government of India, Ministry of Health and Family Welfare. National Population Policy 2000. New Delhi: 2000.
4. Mahila Chetna Manch. Two child policy and its implications for women. Bhopal: unpublished report for the Ministry of Health and Family Welfare; 2004.
5. Venkatesan J. Two child norm upheld. The Hindu, July 31, 2003.
6. Government of India, Ministry of Health and Family Welfare. National Health Policy. New Delhi: 2002.
7. Menon Sreelatha. State-of-the-art cycle pumps. In Mohan Rao (ed), The unheard scream: reproductive health and women's lives in India. New Delhi: Zubaan; 2004. p 21-44.
8. Homan RK and Thankappan KR. An examination of public and private sector sources of in patient care in Trivandrum District, Kerala. Thiruvananthapuram: Achuta Menon Centre for Health Services; 1999.


MOHAN RAO, Centre for Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi 110067, INDIA. e-mail:

Tuesday, August 30, 2005

Docs not liable for failed sterilisation operations: Supreme Court

Docs not liable for failed sterilisation operations: SC
S S Negi
Legal Correspondent

New Delhi, August 29
Holding that a doctor could not be held liable to pay damage for a failed sterilisation operation till any negligence on his part in performing the surgery is proved, the Supreme Court has directed the Union and State Governments to devise a welfare fund or insurance scheme to the persons in whose case operations had been unsuccessful.

“We are...clearly of the opinion that merely because a woman having undergone a sterilisation operation became pregnant and delivered a child, the operating surgeon or his employer cannot be held liable for compensation on account of unwanted pregnancy or unwanted child,” a Bench of Chief Justice R C Lahoti, Mr Justice C K Thakker and Mr Justice P K Balasubramanyan ruled.

The decision came on an appeal by the Punjab Government against awarding of Rs 50,000 compensation by courts below to a woman from Bathinda, who had conceived a child even after she under went a sterilisation operation in August 1984. A woman doctor of a local government hospital had performed the operation.

The woman had claimed a compensation of Rs 3 lakh from Punjab Government’s Health Department in a suit before a civil court for the failure of her operation. But the court directed the state to pay Rs 50,000 to her. The District Judge and the Punjab and Haryana High Court upheld the order of the civil court.

The Medical Officer of Civil Hospital, Bathinda, in his statement had told the civil judge that the “medical science recognises failure of sterilisation operations to the extent of 0.3 to 3 per cent.”

Taking note of it, the Supreme Court said the surgeon could be held liable in contract unless the plaintiff (affected woman) proved that she had been assured 100 per cent exclusion of pregnancy after the surgery and was only on the basis of such assurance that she was persuaded to undergo the operation.

To overcome this problem and without causing any harm to the family planning programme, The government should provide some solace to the person in whose case the operation was unsuccessful on account of “their illiteracy, ignorance or carelessness, the court said

The best course for the government would be to take steps to devise an insurance schemes to the women on whom the operations had been a failure as the rate of such failure was not alarmingly high but negligible considering the vastness of the family welfare programme being undertaken in the country, the court said.

Thursday, August 25, 2005

Supreme Court Appeal (Civil) 5128 of 2002 : Doctors not liable for failed Sterilisation

Appeal (civil) 5128 of 2002

State of Punjab

Shiv Ram & Ors.

DATE OF JUDGMENT: 25/08/2005



R.C. Lahoti, CJI

The plaintiffs-respondents, respectively husband and wife, filed a suit against the State of Punjab, the appellant before us and a lady surgeon who was in the State Government's employment at the relevant time, for recovery of damages to the tune of Rs.3,00,000/- on account of a female child having been born to them in spite of the wife-respondent No. 2 having undergone a tubectomy operation performed by the lady surgeon. According to the plaintiffs-respondents, they already had a son and two daughters from the wed-lock lasting over 17 years. In response to a publicity campaign carried out by the Family Welfare Department of the appellant-State, respondent No. 2 with the consent of respondent No.1, underwent a sterilization operation on 1.8.1984. A certificate in this regard bearing mark of identification No. 505, duly signed by the lady surgeon who performed the said surgery, was issued to her. She was given a cash award of Rs.150/- as an incentive for the operation. On 4.10.1991, respondent No. 2 gave birth to a female child. After serving a notice under Section 80 of the Code of Civil Procedure, a suit for recovery of damages was filed on 15.5.92 attributing the birth of the child to carelessness and negligence of the lady surgeon. The plaint alleged inter alia that the respondents considered abortion to be a sin and that is why after knowing of the conception they did not opt for abortion.

The State was impleaded as defendant No. 1 and the lady surgeon who performed the surgery was impleaded as defendant No.2.

The defendants filed a joint written statement. It was submitted that there was no negligence or carelessness in the performance of the surgery. It is stated in authoritative text books of medical science that pregnancy occurring after sterilization may be attributable to natural failure. It was also submitted that the plaintiffs having learnt of the unwanted pregnancy, should have sought medical opinion and opted for medical termination of pregnancy within 20 weeks which is
permissible and legal.

The parties went to trial. The plaintiff No.1, that is the husband, deposed on oath to substantiate the plaint averments. The wife, plaintiff No.2, did not appear in the witness box. On behalf of the defendants, one Dr. Sham Lal Thukral, Medical Officer, Civil Hospital, Bhatinda appeared to depose that medical science recognises failure of sterilization operations to the extent of 0.3% to 3% and the consequences of such failure can promptly be taken care of by the pregnant woman by undergoing abortion. The deponent produced five extracts (marked as Exhibits D2 to D6) from different textbooks of gynaecology in support of his statement. Original books were
produced for the perusal of the court and returned. The trial court and the first appellate court have not doubted the correctness of the expert medical opinion as expressed in the textbooks cited before the Court. However, the two courts have proceeded on the reasoning that on the birth of a child to a woman who was allured into undergoing sterilization operation by the State in pursuance of its Family Planning Schemes, the State was liable to compensate for the consequences of the
operation having failed. The suit was decreed for Rs.50,000/- with interest and costs. The decree for compensation passed by the trial court has been upheld by the first appellate court. The second appeal preferred by the State has been summarily

At the very outset, the learned Additional Advocate General appearing for the State of Punjab submitted that the appellant-State was not very serious about denying the payment of Rs.50,000/- to the plaintiffs-respondents as they are poor persons, but the State was certainly interested in having the legal issue resolved. He further submitted that the filing of such suits in the civil court or complaints before the Consumer Fora, are on an increase and decrees are being passed against the State without any basis in law and, therefore, the position of law needs to be clarified and settled.

Very recently, this Court has dealt with the issues of medical negligence and laid down principles on which the liability of a medical professional is determined generally and in the field of criminal law in particular. Reference may be had to Jacob Mathew v. State of Punjab & Anr. (2005) 6 SCC 1. The Court has approved the test as laid down in Bolam v. Friern Hospital Management Committee, [1957] 1 W.L.R. 582, popularly known as Bolam's Test, in its applicability to India. The relevant principles culled out from the case of Jacob Mathew (supra) read as under:

(1) Negligence is the breach of a duty caused by omission to
do something which a reasonable man guided by those
considerations which ordinarily regulate the conduct of
human affairs would do, or doing something which a
prudent and reasonable man would not do. The definition
of negligence as given in Law of Torts, Ratanlal & Dhirajlal
(edited by Justice G.P. Singh), referred to hereinabove,
holds good. Negligence becomes actionable on account of
injury resulting from the act or omission amounting to
negligence attributable to the person sued. The essential
components of negligence are three: 'duty', 'breach' and
'resulting damage'.

(2) A simple lack of care, an error of judgment or an accident,
is not proof of negligence on the part of a medical
professional. So long as a doctor follows a practice
acceptable to the medical profession of that day, he cannot
be held liable for negligence merely because a better
alternative course or method of treatment was also
available or simply because a more skilled doctor would
not have chosen to follow or resort to that practice or
procedure which the accused followed. When it comes to
the failure of taking precautions what has to be seen is
whether those precautions were taken which the ordinary
experience of men has found to be sufficient; a failure to
use special or extraordinary precautions which might have
prevented the particular happening cannot be the standard
for judging the alleged negligence.

(3) A professional may be held liable for negligence on one of
the two findings: either he was not possessed of the
requisite skill which he professed to have possessed, or, he
did not exercise, with reasonable competence in the given
case, the skill which he did possess. The standard to be
applied for judging, whether the person charged has been
negligent or not, would be that of an ordinary competent
person exercising ordinary skill in that profession. It is not
possible for every professional to possess the highest level
of expertise or skills in that branch which he practices. A
highly skilled professional may be possessed of better
qualities, but that cannot be made the basis or the
yardstick for judging the performance of the professional
proceeded against on indictment of negligence.

This Court has further held in Jacob Mathew's case
"Accident during the course of medical or
surgical treatment has a wider meaning.
Ordinarily, an accident means an unintended
and unforeseen injurious occurrence;
something that does not occur in the usual
course of events or that could not be
reasonably anticipated (See, Black's Law
Dictionary, 7th Edition). Care has to be taken
to see that the result of an accident which is
exculpatory may not persuade the human mind
to confuse it with the consequence of

The plaintiffs have not alleged that the lady surgeon who
performed the sterilization operation was not competent to
perform the surgery and yet ventured into doing it. It is neither
the case of the plaintiffs, nor has any finding been arrived at by
any of the courts below that the lady surgeon was negligent in
performing the surgery. The present one is not a case where
the surgeon who performed the surgery has committed breach
of any duty cast on her as a surgeon. The surgery was
performed by a technique known and recognized by medical
science. It is a pure and simple case of sterilization operation
having failed though duly performed. The learned Additional
Advocate General has also very fairly not disputed the vicarious
liability of the State, if only its employee doctor is found to have
performed the surgery negligently and if the unwanted
pregnancy thereafter is attributable to such negligent act or
omission on the part of the employee doctor of the State.

The learned Advocate General has brought to our notice a
number of textbooks on gynaecology. We refer to some of them.

In Jeffcoate's Principles of Gynaecology, revised by
V.R. Tindall, MSc.,MD,FRCSE, FRCOG, Professor of Obstetrics
and Gynaecology, University of Manchester (Fifth Edition)
published by Butterworth Heinemann, the following technique of
female sterilization are stated:
"Female Sterilization

1. Radiotherapy

A menopausal dose of external beam
irradiation to the ovaries is only attractive in so
far that they sterilize without involving the
woman in an operation. Their disadvantages
(as stated at pages 93 and 528) are such that
they are rarely used except in older women
who are seriously ill.

2. Removal of the ovaries

This sterilizes (provided an accessory ovary is
not overlooked) but is very rarely indicated as
it often results in severe climacteric symptoms.

3. Removal of the uterus

This is effective but involves an unnecessarily
major operation and destroys menstrual as
well as reproductive function. Its chief place is
in those cases where the need for sterilization
is associated with disease in the uterus or
cervix. But, to preclude further childbearing, it
is commonly carried out as part of another
operation. Examples are vaginal hysterectomy
as part of the cure of prolapse, and caesarean
hysterectomy. The latter is sometimes
advocated, in preference to caesarean section
and tubal ligation, on the grounds that it
prevents future uterine disease as well as
conception. Those women who have ethical
objections to tubal ligation may well prefer to
have a 'scarred uterus' removed. Except in
special circumstances, however, caesarean
hysterectomy is not justified as a sterilization

As an elective sterilization procedure for
non-pregnant women, some gynaecologists
advocate hysterectomy (preferably vaginal) in
preference to tubal resection. This is because it
removes the possibility of the future
development of uterine disease such as
carcinoma of the cervix and eliminates the
chance of the woman suffering menstrual and
other upsets which sometimes follow less
radical procedures. Hysterectomy, however,
carries a much higher immediate morbidity
rate than does surgical tubal resection and can
be followed by other disturbances and regrets
at loss of menstrual function  an outward
sign of femininity."

4. Resection of fallopian tubes

Provided the pelvic organs are healthy,
one of the best methods is to remove 1-2 cm
of the middle of each tube and to bury the
ligated ends separately under the peritoneum.
Sometimes the cornua of the uterus are
excised, together with the adjacent portions of
the tubes. Excision of the whole of both tubes
is not so safe because it leaves the ovum free
to wander into a possible uterine fistula and
fimbriectomy should never be performed.
Retention of the abdominal ostia is an
advantage for it tends to ensure that ova
become trapped in the occluded tubes.

Of the more simple operations on the
fallopian tubes the best is the Pomeroy
procedure in which a loop of tube is excised
and the cut ends secured with a ligature. This
method has the advantage of avoiding
troublesome haemorrhage which can attend
the techniques described above, requires only
limited access, is speedy, and fails in not more
than 0.3 per cent of cases. The technique of
crushing and ligation of the tubes without
excising any part of them (Madlener operation)
is very unreliable, the failure rate being 3.0 per
cent; it is rarely practised now.

Whatever technique be used for dividing
the tubes, it is important to ligature their cut
ends with plain catgut. This is much more
likely to result in firm closure than is the use of
unabsorbable material, or even chromic gut.
Most failures are due to neglect of this
medicolegally very important point.

Resection of the tubes is usually carried
out abdominally and is particularly easy to
perform 2-4 days after delivery when the
uterus is an abdominal organ and the tubes
readily accessible. It can then, if necessary,
be carried out under local analgesia. Tubal
resection (preferably using the Pomeroy
technique) can also be performed vaginally
either during the course of another operation
or as the route of choice. As a method of
choice it is not new as is sometimes
suggested; it was regularly carried out in the

Dealing with reliability of the sterilization procedures
performed and commonly employed by the gynaecologists, the
text book states (at p.621):-
The only sterilization procedures in the female
which are both satisfactory and reliable are:
resection or destruction of a portion of both
fallopian tubes; and hysterectomy. No
method, however, is absolutely reliable and
pregnancy is reported after subtotal and total
hysterectomy , and even after hysterectomy
with bilateral salpingectomy. The explanation
of these extremely rare cases is a persisting
communication between the ovary or tube and
the vaginal vault.

Even when tubal occlusion operations are
competently performed and all technical
precautions are taken, intrauterine pregnancy
occurs subsequently in 0.3 per cent of cases.
This is because an ovum gains access to
spermatozoa through a recanalized inner
segment of the tube.

There is clinical impression that tubal
resection operations are more likely to fail
when they are carried out at the time of
caesarean section than at any other time. The
fact that they occasionally fail at any time has
led many gynaecologists to replace the term
'sterilization' by "tubal ligation" or "tubal
resection" in talking to the patient and in all
records. This has real merit from the
medicolegal standpoint."

[underlining by us]

In Shaw's Textbook of Gynaecology , after describing
several methods of female sterilization, the textbook states that
the most popular technique adopted in Mini-lapartomy
sterilization is Pomeroy method in which the fallopian tube is
identified on each side, brought out through the incision, and the
middle portion is formed into a loop which is tied at the base
with catgut and excised. The failure rate is only 0.4% and it is
mainly due to spontaneous recanalization. The operation is
simple, requires a short hospitalization, does not require any
sophisticated and expensive equipment like a laparoscope, and
can be performed in a primary health centre by a doctor trained
in this procedure. In Madlener method, a loop of the tube is
crushed and ligated with a non-absorbable suture. Failure rate
is of 7% and occurrence of an ectopic pregnancy are
unacceptable though it is a simple procedure to perform. There
are other methods, less popular on account of their indications,
which are also stated. Dealing with the topic of complications
and sequelae of sterilization, the textbook states:

"Failure rate of sterilization varies from 0.4%
in Pomeroy's technique, 0.3-0.6% by
laparoscopic method to 7% by Madlener
method. Pregnancy occurs either because of
faulty technique or due to spontaneous

In 'The Essentials of Contraceptive Technology',
written by four doctors and published by Center for
Communication Programs, The Johns Hopkins School of Public
Health in July, 1997, certain questions and answers are stated.
Questions 5 and 6 and their answers, which are relevant for our
purpose, read as under:

"5. Will female sterilization stop working
after a time? Does a woman who had a
sterilization procedure ever have to worry
about getting pregnant again?

Generally, no. Female sterilization should be
considered permanent. Failure rates are
probably higher than previously thought
however. A major new US study found that the
risk of pregnancy within 10 years after
sterilization is about 1.8 per 100 women 
about 1 in every 55 women. The risk of
sterilization failure is greater for younger
women because they are more fertile than
older women. Also, some methods of blocking
the tubes work better than others. Methods
that cut away part of each tube work better
than spring clips or bipolar electrocoagulation
(electric current). Effectiveness also depends
on the skill of the provider.

The same US study found that 1 of every 3
pregnancies after sterilization was ectopic. If a
woman who has had sterilization ever thinks
that she is pregnant or has an ectopic
pregnancy, she should seek help right away.

[underlining by us]

6. Pregnancy after female sterilization is
rare but why does it happen at all?

The most common reason is that the woman
was already pregnant at the time of
sterilization. Pregnancy also can occur if the
provider confused another structure in the
body with the fallopian tubes and blocked or
cut the wrong place. In other case pregnancy
results because clips on the tubes come open,
because the ends of the tubes grow back
together, or because abnormal openings
develop in the tube, allowing sperm and egg to

In newsletter "alert" September, 2000 issue, Prof.(Dr.)
Gopinath N. Shenoy writes:

"Female sterilization can be done by many
methods/techniques, which are accepted by
the medical professionals all over the world. It
is also an accepted fact that none of these
methods/techniques are cent percent 'failure
free'. This 'failure rate' may vary from method
to method. A doctor is justified in choosing
one method to the exclusion of the others and
he cannot be faulted for his choice if his choice
is based on reasonable application of mind and
is not 'palpably' wrong. A doctor has
discretionary powers to choose the
method/technique of sterilization he desires to

[emphasis supplied]

In "The New England Journal of Medicine" , owned,
published and copyrighted by Massachusetts Medical Society, the
result of a research carried out by a team of doctors has been
published and widely circulated. 10,685 women enrolled and
eligible for long term follow up and willing to cooperate and
providing information were studied. The relevant part of the
result of the study reads as under:

"The median age of women at the time of
sterilization was 30 years (range, 18 to 44;
mean [+ SD],31+6). Most women were white
and had been pregnant at least twice (Table
1). In all, 143 women (1.3 percent) reported
pregnancies that were classified as true failure
of sterilization. For 66.4 percent of these
pregnancies, the classification was based on a
review of medical reports by the investigators.
The remainder were classified on the basis of
the woman's history alone."

In Medico-legal Aspects in Obstetrics and
Gynaecology, edited by three doctors, Chapter 18, deals with
Medico-legal Problems in Sterilization Operations. It is stated
therein that there are several methods of female sterilization of
which one that will suit the patient and the
surgeon/gynaecologist should be selected. In India, Pomeroy's
method is widely practised. Other methods include  Madlener's,
Irving's, Uchida's methods and so on. The text further states
that failure is one of the undesirous outcome of sterilization.
The overall incidence of failure in tubectomy is 0.4 per 100
women per year. The text describes the following events
wherefrom sterilization failure usually results:
i. Spontaneous recanalisation or fistula formation
is perhaps the most common cause of failure.
Though these are generally non-negligent
causes of failure, it is very difficult to convince
the patient if they are not informed beforehand
about the possibility.

ii. Undetected pregnancy at the time of
sterilization is an indefensible offence. To
avoid such incidence, tests to detect pregnancy
should be done before sterilization operation is

iii. Imperfect occlusion of the tube is a technical
loophole which may result in an unwanted
pregnancy. The chance is particularly high in
laparoscopic methods. If a gynaecologist fails
to place ring on any one of the tube due to
improper visualization, he or she must inform
the patient and her husband, and some other
contraceptive method should be advised.

iv. Occlusion of the wrong structure(s), e.g. round
ligament is a common, indefensible error which
may particularly happen if the surgeon is
inexperienced. This is more frequent in
laparoscopic methods where even confirmation
of the structure by biopsy is difficult, in case of

It is thus clear that there are several alternative methods
of female sterilization operation which are recognized by medical
science of today. Some of them are more popular because of
being less complicated, requiring minimal body invasion and
least confinement in the hospital. However, none is foolproof
and no prevalent method of sterilization guarantees 100%
success. The causes for failure can well be attributable to the
natural functioning of the human body and not necessarily
attributable to any failure on the part of the surgeon.
Authoritative Text Books on Gynaecology and empirical
researches which have been carried out recognize the failure
rate of 0.3% to 7% depending on the technique chosen out of
the several recognized and accepted ones. The technique which
may be foolproof is removal of uterus itself but that is not
considered advisable. It may be resorted to only when such
procedure is considered necessary to be performed for purposes
other than merely family planning.

An English decision Eyre v. Measday (1986) 1 ALL ER 488
is very near to the case at hand. The facts of the case were that
in 1978, the plaintiff and her husband decided that they did not
wish to have any more children. The plaintiff consulted the
defendant gynaecologist with a view to undergoing a sterilization
operation. The defendant explained to the couple the nature of
the particular operation he intended to perform, emphasising
that it was irreversible. He stated that the operation 'must be
regarded as a permanent procedure' but he did not inform the
plaintiff that there was a small risk (less than 1%) of pregnancy
occurring following the operation. Consequently, both the
plaintiff and her husband believed that the result of the
operation would be to render her absolutely sterile and incapable
of bearing further children. In 1979 the plaintiff became
pregnant and gave birth to a child. The plaintiff brought an
action against the defendant for damages, inter alia, for breach
of contract, contending that his representation that the operation
was irreversible and his failure to warn her of the minute risk of
the procedure being unsuccessful, amounted to breach of a
contractual term, or express or implied collateral warranty, to
render her irreversibly sterile. The judge dismissed her claim
and the plaintiff appealed to the Court of Appeal.

The Court held 

"(1) The contract undertaken by the defendant
was to carry out a particular type of operation
rather than to render the plaintiff absolutely
sterile. Furthermore, the defendant's
representations to the plaintiff that the
operation was 'irreversible' did not amount to
an express guarantee that the operation was
bound to achieve its acknowledged object of
sterilizing the plaintiff. On the facts, it was
clear that the representations meant no more
than that the operative procedure in question
was incapable of being reversed.

(2) Where a doctor contracted to carry out a
particular operation on a patient and a
particular result was expected, the court would
imply into the contract between the doctor and
the patient a term that the operation would be
carried out with reasonable care and skill, but
would be slow to imply a term or unqualified
collateral warranty that the expected result
would actually be achieved, since it was
probable that no responsible medical man
would intend to give such a warranty. On the
facts, no intelligent lay bystander could have
reasonably inferred that the defendant was
intending to give the plaintiff a guarantee that
after the operation she would be absolutely
sterile and the fact that she believed that this
would be the result was irrelevant."

The appeal was dismissed. The Court of Appeal, upheld
the finding of the trial judge that the risk of pregnancy following
such a procedure to which the plaintiff was subjected is
described as very small. It is of the order of 2 to 6 in every
1000. There is no sterilization procedure which is entirely
without such a risk.

Slade L J, stated in his opinion that "in the absence of any
express warranty, the court should be slow to imply against a
medical man an unqualified warranty as to the results of an
intended operation, for the very simple reason that, objectively
speaking, it is most unlikely that a responsible medical man
would intend to give a warranty of this nature. Of course,
objectively speaking, it is likely that he would give a guarantee
that he would do what he had undertaken to do with reasonable
care and skill; but it is quite another matter to say that he has
committed himself to the extent suggested in the present case."

Purchas LJ, stated in his opinion that "it is true that as a
matter of deliberate election the defendant did not, in the course
of describing the operation which he was recommending,
disclose that there was a very small risk, one might almost say
an insignificant risk, that the plaintiff might become pregnant.
In withholding this information it must be borne in mind, first
that the defendant must have believed that the plaintiff would be
sterile, second that the chances were extremely remote that the
operation would be unsuccessful, third that in withholding this
information the defendant was following a practice acceptable to
current professional standards and was acting in the best
interest of the plaintiff, and fourth that no allegation of
negligence in failing to give this information to the plaintiff is
pursued any longer in this case. There are, therefore, in my
judgment, no grounds for asserting that the result would
necessarily be 100% successful."

In Thake v Morris , [1986] 1 All ER 497 (CA) the claim
for damages was founded on contract and not in torts. The
Court of Appeal firmly rejected the possibility of an enforceable
warranty. Neill L J said:

"a reasonable man would have expected the
defendant to exercise all the proper skill and care of
a surgeon in that speciality: he would not have
expected the defendant to give a guarantee of 100%

Nourse L J said:

"of all sciences medicine is one of the least exact. In
my view, a doctor cannot be objectively regarded as
guaranteeing the success of any operation or
treatment unless he says as much in clear and
unequivocal terms."

We are, therefore, clearly of the opinion that merely
because a woman having undergone a sterilization operation
became pregnant and delivered a child, the operating surgeon or
his employer cannot be held liable for compensation on account
of unwanted pregnancy or unwanted child. The claim in tort can
be sustained only if there was negligence on the part of the
surgeon in performing the surgery. The proof of negligence shall
have to satisfy Bolam's test. So also, the surgeon cannot be
held liable in contract unless the plaintiff alleges and proves that
the surgeon had assured 100 % exclusion of pregnancy after the
surgery and was only on the basis of such assurance that the
plaintiff was persuaded to undergo surgery. As noted in various
decisions which we have referred to hereinabove, ordinarily a
surgeon does not offer such guarantee.

The cause of failure of sterilization operation may be
obtained from laparoscopic inspection of the uterine tubes, or by
x-ray examination, or by pathological examination of the
materials removed at a subsequent operation of re-sterilisation.
The discrepancy between operation notes and the result of x-ray
films in respect of the number of rings or clips or nylon sutures
used for occlusion of the tubes, will lead to logical inference of
negligence on the part of the gynaecologist in case of failure of
sterilisation operation. (See: Law of Medical Negligence and
Compensation by R.K. Bag, Second Edition, p.139)

Mrs. K. Sarada Devi, the learned counsel appearing for the
plaintiffs-respondents placed reliance on a 2-Judge Bench
decision of this Court in State of Haryana & Ors. v. Smt.
Santra, JT 2000 (5) SC 34, wherein this Court has upheld the
decree awarding damages for medical negligence on account of
the lady having given birth to an unwanted child on account of
failure of sterilization operation. The case is clearly
distinguishable and cannot be said to be laying down any law of
universal application. The finding of fact arrived at therein was
that the lady had offered herself for complete sterilization and
not for partial operation and, therefore, both her fallopian tubes
should have been operated upon. It was found as a matter of
fact that only the right fallopian tube was operated upon and the
left fallopian tube was left untouched. She was issued a
certificate that her operation was successful and she was
assured that she would not conceive a child in future. It was in
these circumstances, that a case of medical negligence was
found and a decree for compensation in tort was held justified.
The case thus proceeds on its own facts.

The methods of sterilization so far known to medical
science which are most popular and prevalent are not 100% safe
and secure. In spite of the operation having been successfully
performed and without any negligence on the part of the
surgeon, the sterilized woman can become pregnant due to
natural causes.
Once the woman misses the menstrual cycle, it
is expected of the couple to visit the doctor and seek medical
advice. A reference to the provisions of the Medical Termination
of Pregnancy Act, 1971 is apposite. Section 3 thereof permits
termination of pregnancy by a registered medical practitioner,
notwithstanding anything contained in the Indian Penal Code,
1860 in certain circumstances and within a period of 20 weeks
of the length of pregnancy. Explanation II appended to sub-
section (2) of Section 3 provides ____
"Explanation II. ____ Where any pregnancy
occurs as a result of failure of any device or
method used by any married woman or her
husband for the purpose of limiting the number of
children, the anguish caused by such unwanted
pregnancy may be presumed to constitute a grave
injury to the mental health of the pregnant

And that provides, under the law, a valid and legal ground
for termination of pregnancy. If the woman has suffered an
unwanted pregnancy, it can be terminated and this is legal and
permissible under the Medical Termination of Pregnancy Act,

The cause of action for claiming compensation in cases of
failed sterilization operation arises on account of negligence of
the surgeon and not on account of child birth. Failure due to
natural causes would not provide any ground for claim. It is for
the woman who has conceived the child to go or not to go for
medical termination of pregnancy. Having gathered the
knowledge of conception in spite of having undergone
sterilization operation, if the couple opts for bearing the child, it
ceases to be an unwanted child. Compensation for maintenance
and upbringing of such a child cannot be claimed.

For the foregoing reasons, we are of the opinion that the
judgments and the decrees passed by the High Court and courts
below cannot be sustained. The trial court has proceeded to
pass a decree of damages in favour of the plaintiffs-respondents
solely on the ground that in spite of the plaintiff-respondent No.2
having undergone a sterilization operation, she became
pregnant. No finding has been arrived at that will hold the
operating surgeon or its employer __ the State, liable for
damages either in contract or in tort. The error committed by
the trial court, though pointed out to the first appellate court and
the High Court, has been overlooked. The appeal has, therefore,
to be allowed and the judgment and decree under appeal have
to be set aside.

We have decided the question of law and held that the
decree awarding the damages was totally uncalled for and had
no foundation in law, and therefore, has to be set aside. The
present case is an occasion, which we would like to utilize for the
purpose of making certain observations on three related topics
noted hereunder.

(1) Jacob Mathew's case (2005) 6 SCC1 : a post script

In Jacob Mathew this Court dealt with the liability of a
medical practitioner in criminal law. Of course, the decision also
discussed in detail the law of medical negligence in general and
indicated the parameters of fixing liability. The distinction
between the concept of negligence in civil law and negligence in
criminal law was highlighted. The present case deals with the
law of negligence in tort. The basis of liability of a professional
in tort is negligence. Unless that negligence is established, the
primary liability cannot be fastened on the medical practitioner.
Unless the primary liability is established, vicarious liability on
the State cannot be imposed. Both in criminal jurisprudence and
in civil jurisprudence, doctors are liable for consequences of
negligence. In Jacob Mathew even while dealing with criminal
negligence, this Court has indicated the caution needed in
approaching a case of medical negligence having regard to the
complexity of the human body which is subjected to treatment
and the uncertainty involved in medical procedures. A doctor, in
essence, needs to be inventive and has to take snap decisions
especially in the course of performing surgery when some
unexpected problems crop up or complication sets in. If the
medical profession, as a whole, is hemmed in by threat of action,
criminal and civil, the consequence will be loss to the patients.
No doctor would take a risk, a justifiable risk in the
circumstances of a given case, and try to save his patient from a
complicated disease or in the face of an unexpected problem
that confronts him during the treatment or the surgery. It is in
this background that this Court has cautioned that the setting in
motion of the criminal law against the medical profession should
be done cautiously and on the basis of reasonably sure grounds.
In criminal prosecutions or claims in tort, the burden always
rests with the prosecution or the claimant. No doubt, in a given
case, a doctor may be obliged to explain his conduct depending
on the evidence adduced by the prosecution or by the claimant.
That position does not change merely because of the caution
advocated in Jacob Mathew in fixing liability for negligence, on

(2) How the medical profession ought to respond

Medical profession is one of the oldest professions of the
world and is the most humanitarian one. There is no better
service than to serve the suffering, wounded and the sick.
Inherent in the concept of any profession is a code of conduct,
containing the basic ethics that underline the moral values that
govern professional practice and is aimed at upholding its
dignity. Medical Ethics underpins the values at the heart of the
practitioner-client relationship. In the recent times, professionals
are developing a tendency to forget that the self-regulation
which is at the heart of their profession is a privilege and not a
right and a profession obtains this privilege in return for an
implicit contract with society to provide good, competent and
accountable service to the public. It must always be kept in mind
that doctor's is a noble profession and the aim must be to serve
humanity, otherwise this dignified profession will lose its true

Medical profession has long subscribed to a body of ethical
statements developed primarily for the benefit of the patient.
The oldest expression of this basic principle comes from
Hippocrates, an early Greek Physician, born in 460 B.C. who
came to be known as the "Father of Medicine" and had devoted
his entire life to the advancement of medical science. He
formulated a code of conduct in the form of the Hippocratic
Oath, as he realized that knowledge and skill were not enough
for a physician without a code of standards and ideals. He coined
an oath of integrity for physicians, a code of standards and
ideals to which they must swear to adhere in the practice of their
profession. This continues till date to be the oath administered
to doctors when they join the profession:
"I swear by Apollo the physician, by Fsculapius, Hygeia,
and Panacea, and I take to witness all the gods, all the
goddesses, to keep according to my ability and my
judgement, the following Oath.

To consider dear to me as my parents him who taught me
this art; to live in common with him and if necessary to
share my goods with him; to look upon his children as my
own brothers, to teach them this art if they so desire
without fee or written promise; to impart to my sons and
the sons of the master who taught me and the disciples
who have enrolled themselves and have agreed to the
rules of the profession, but to these alone the precepts and
the instruction. I will prescribe regimens for the good of
my patients according to my ability and my judgement and
never do harm to anyone. To please no one will I prescribe
a deadly drug nor give advice which may cause his death.
Nor will I give a woman a pessary to procure abortion. But
I will preserve the purity of my life and my art. I will not
cut for stone, even for patients in whom the disease is
manifest; I will leave this operation to be performed by
practitioners, specialists in this art. In every house where I
come I will enter only for the good of my patients, keeping
myself far from all intentional ill-doing and all seduction
and especially from the pleasures of love with women or
with men, be they free or slaves. All that may come to my
knowledge in the exercise of my profession or in daily
commerce with men, which ought not to be spread abroad,
I will keep secret and will never reveal. If I keep this oath
faithfully, may I enjoy my life and practice my art,
respected by all men and in all times; but if I swerve from
it or violate it, may the reverse be my lot."

Many versions of Hippocratic Oath are prevalent. "Light
From Many Lamps" a book edited by Lilian Eichler Watson
contains a little different phraseology of that oath but certainly a
beautiful commentary on the significance of the Hippocratic
Oath. We would like to reproduce the oath and the commentary
hereunder: (pages 181-182);
"I do solemnly swear by that which I hold most

That I will be loyal to the profession of
medicine and just and generous to its members;

That I will lead my life and practice my art in
uprightness and honor;

That into whatsoever house I shall enter, it
shall be for the good of the sick to the utmost of my
power, I holding myself aloof from wrong, from
corruption, and from the temptation of others to

That I will exercise my art solely for the cure of
my patients, and will give no drug, perform no
operation for a criminal purpose, even if solicited, far
less suggest it;

That whatsoever I shall see or hear of the lives
of men which is not fitting to be spoken, I will keep
inviolably secret.

These things I do promise, and in proportion as
I am faithful to this my oath may happiness and
good repute be ever mine __ the opposite if I shall be

[F.N.: The Hippocratic Collection, containing
the best of the ancient Greek medical writings, was
put together by Aristotle and has survived through
the centuries. The "Hippocratic Oath" is one of the
last and most inspiring passages in this Collection.
There are a number of versions of the famous Oath;
but the form given here is the one commonly used
today; and is an adaptation of a translation from the
original Greek.]

"The medical profession is and always has been one
of the most ethical of all professions; and this is due
at least in part to the centuries-old influence of the
Hippocratic Oath. This famous Oath has kept alive
the high standards and ideals set by Hippocrates,
and forms the basis of modern medical ethics.

Written more than twenty centuries ago, the
Hippocratic Oath has inspired generations of doctors
. . . and continues to do so even now. The Oath is
still administered by medical schools to graduating
classes; and thousands of physicians have framed
copies on their walls along with their diplomas.
Conscientious practitioners continue to live up to the
principles and ideals set down for their profession so
long ago by the "Father of Medicine."

Though it was written specifically for
physicians, the Hippocratic Oath sets an enduring
pattern of honor, integrity, and devotion to duty for
all people, in all professions." And certainly to

Many people argue that the original Hippocratic Oath is
inappropriate in a society that has seen drastic socio-economic,
political and moral changes, since the time of Hippocrates.
Certain parts of the original oath such as teaching the master's
sons the secrets of medicine without fees and the promise not to
bring a knife to another's body but to leave it to 'practitioners of
the craft' have been rendered obsolete as the modernisation of
education has led to the teaching of medical science in
institutions of higher learning, and specialisation in medicine has
led to physicians who specialise in a variety of fields including
surgery. Similarly, the legalisation on abortion and physician-
assisted suicide in certain parts of the world, has made it
awkward for some medical practitioners there to carry on in the
tradition of the original oath.
This has led to the modification of the oath to something
better suited for our times. One of the most widely used versions
is The Declaration of Geneva which was adopted by the
General Assembly of the World Medical Association at Geneva in
1948. Written with the medical crimes committed in Nazi
Germany in view, it is a 'declaration of physicians' dedication to
the humanitarian goals of medicine.' It is also perhaps the only
one to mention treating people equally, without regard as to
race, religion, social standing and political affiliations:
"I solemnly pledge myself to the service of humanity. I
will give to my teachers the respect and gratitude which
is their due. I will practice my profession with conscience
and dignity. The health of my patient will be my first
consideration. I will respect the secrets which are
confided in me. I will maintain by all means in my power
the honour and noble traditions of the medical profession.
My colleagues will be my brothers and sisters. I will not
permit consideration of religion, nationality, race or social
standing to intervene between my duty and my patient. I
will maintain the utmost respect for human life even
under threat. I will not use my medical knowledge
contrary to the laws of humanity. I make these promises
solemnly, freely and upon my honour."

In recent times the self regulatory standards in the
profession have shown a decline and this can be attributed to
the overwhelming impact of commercialization of the sector.
There are reports against doctors of exploitative medical
practices, misuse of diagnostic procedures, brokering deals for
sale of human organs, etc. It cannot be denied that black sheep
have entered the profession and that the profession has been
unable to isolate them effectively. The need for external
regulation to supplement professional self-regulation is
constantly growing. The high costs and investments involved in
the delivery of medical care have made it an entrepreneurial
activity wherein the professionals look to reaping maximum
returns on such investment. Medical practice has always had a
place of honour in society; currently the balance between service
and business is shifting disturbingly towards business and this
calls for improved and effective regulation, whether internal or
external. There is need for introspection by doctors  individually
and collectively. They must rise to the occasion and enforce
discipline and high standards in the profession by assuming an
active role.

(3) Need for devising a welfare fund or insurance scheme

Failure of many a sterilization operation, though
successfully performed, is attributable to causes other than
medical negligence as we have already discussed hereinabove.
And, yet the doctors are being faced with claim for damages.
Some of the claims have been decreed by the courts without
arriving at any finding providing a foundation in law for
upholding such a claim. The state is also being called upon to
honour such decrees on the principle of vicarious liability when
the surgeon has performed a surgery in discharge of his duty.
Mostly such surgeries are performed on a large scale and as a
part of family welfare programmes of the Government.
Obviously, such programmes are in public interest. Such like
decrees act as a disincentive and have deterrent effect on the
surgeons performing sterilization operations. The State, flooded
with such decrees is also inclined not to pursue family planning
camps on large scale though in public interest.

In Javed & Ors. v. State of Haryana & Ors. (2003) 8
SCC 369, popularly known as 'Two-Child Norm' case, this Court
had an occasion to deal with the problem of increasing
population, the danger which it poses for the progress of the
nation and equitable distribution of its resources and upheld the
validity of the Haryana legislation imposing a disqualification on
persons having more than two children from contesting for an
elective office. The fact cannot be lost sight of that while
educated persons in the society belonging to the middle-class
and the upper class do voluntarily opt for family planning and
are careful enough to take precautions or remedial steps to
guard against the consequences of failure of sterilization, the
illiterate and the ignorant and those belonging to the lower
economic strata of society face the real problem. To popularize
family planning programmes in such sections of society, the
State Government should provide some solace to them if they,
on account of their illiteracy, ignorance or carelessness, are
unable to avoid the consequences of a failed sterilization
operation. Towards this end, the State Governments should
think of devising and making provisions for a welfare fund or
taking up with the insurance companies, a proposal for devising
an appropriate insurance policy or an insurance scheme, which
would provide coverage for such claims where a child is born to
woman who has undergone a successful sterilization operation,
as in the present case.

The appeal is allowed. The judgment and decree passed by the trial court and upheld by the first appellate court and the High Court are set aside. The suit filed by the plaintiffs-respondents is dismissed. However, as we have already stated, in view of the concession given by the learned Additional Advocate General appearing for the appellant State, the amount of Rs.50,000/- if already paid to the plaintiff-respondent shall not be liable to be refunded by way of restitution. No order as to