Complications in Neurosurgery: General Ethical Principles for Minimizing Them and Subsequent Legal Action.

Medicine and surgery carry inherent risks of inadvertent and unintended harm to the patient. Training, experience, and skill help ensure smooth recovery in most cases. However, there are circumstances beyond the control of the neurosurgeon that may predispose to complications. This review discusses steps that may help to diminish risks to the patient and can be taken before their admission to hospital, in the operating theater, and after surgery. When a complication does occur despite all care, it is essential to maintain total transparency with the patient and his or her family. It is important that they are active witnesses to the care and treatment being lavished on the individual to minimize the harm from the mishap. Should legal action follow despite such efforts, the neurosurgeon must be prepared to defend with the help of a wise, experienced lawyer and to provide evidence of his or her professional competence and the appropriateness of care offered to the patient. In any case, it is counterproductive to view every patient as a potential legal threat or indulge in defensive medical practice.

Indian Journal of Medical Ethics - retrospect and prospect.

As the Indian Journal of Medical Ethics (IJME) nears the age of thirty years, it is well to undertake a review of its performance.

Centring patient autonomy in DNAR decisions.

The Response from the ICMR team of Dr Mani et al (1) to the IJME Editorial (2) on the ICMR DNAR Guidelines (3) provides some answers to the gaps and questions raised, and it is hoped that these will find a place in revised versions of the document. The document Disclaimer said "further revisions" were planned, based on perceptions and experiences of clinicians and the public; an early revision will allow for better acceptance of the Guidelines.

Pernkopf's atlas: Should unethically obtained life-saving data be discarded?

Dr Pernkopf's Topographische anatomie des menschen (Topographical anatomy of man), in four volumes, was originally published in German. It had taken the author and his colleagues over twenty years to produce it, the first volume being published in 1937. It was translated into English in 1964. The atlas was received with uniform acclaim in Europe and America and praised for its accuracy and the quality of its illustrations. A recent study compared its utility with that of Dr Frank Netter's Atlas of human anatomy, first published in 1989, with its 7th edition out in 2018. "The respondents (nerve surgeons) found Pernkopf 's atlas having both greater anatomical detail (range 79%-91%) and greater utility for surgery (range 66%- 82%) when compared with Netter's (P < .001) in all plate comparisons." (1) Internationally renowned and respected neurosurgeon, Dr M Gazi Yasargil - not given to handing out praise lightly - said in 2004 of this atlas, "Pernkopf's work, in particular … Vol. 4 (800 pages, 218 figures) is of fantastic quality and is appreciated worldwide." (2) Surgeons continue to use Dr. Pernkopf's atlas to plan their operations (3). A recent example is its use in the treatment of a 13-year-old Israeli schoolboy (4). This essay discusses whether it is rational to refuse to use data and publications that are accurate and likely to help in treating patients. Since such information can save lives, should we spurn it because it was based on information obtained unethically?

Confidentiality vs harm to another.

Dr. Bawaskar's sensitivity in this matter deserves applause (1). The principle of confidentiality dictates that what is discussed by doctor and patient remains between them and should not be divulged to anyone else without the patient's express consent.

Women in the neurosciences.

The term 'scientist' was coined to describe Mary Somerville (1780-1872) as her contributions to astronomy commanded recognition of her excellence in science. Up to then, the term 'man of science' had been in use. In fields traditionally considered the province of males, the entry of women was viewed with consternation, apprehension and alarm. Resistance was instinctive in most leading scientists. This attitude was strengthened by illogical and pseudoscientific statements on the frailty of women. The pioneers blazing trails in medicine for their sisters to follow braved ridicule, hostility, and discrimination. At times they used subterfuge. The example of Dr. James Barry (Margaret Ann Bulkley) is well-known. Thanks to them, we now have nationally and internationally eminent scientists from the gentler sex, and some of them in commanding positions. The neurosciences developed in India as a result of the efforts made by pioneer neurosurgeons such as Drs. Jacob Chandy (Vellore), B. Ramamurthi (Madras), R.G. Ginde (Bombay), Dr. Prakash N. Tandon (New Delhi) and neurophysicians such as Drs. Baldev Singh (New Delhi), T.K. Ghosh (Calcutta) and Noshir H. Wadia (Mumbai). They and others such as Drs. V.R. Khanolkar, Darab K. Dastur, B.K. Bachhawat and Obaid Siddiqui encouraged individuals like Dr. Vimla Virmani, Dr. Devika Nag, Dr. T.S. Kanaka and Dr. Gourie Devi in the clinical neurosciences and Drs. Kamal Ranadive, V.S. Lalitha, Veronica Rodrigues and Gomathy Gopinath in the basic neurosciences. Two eminent neuroscientists from abroad (Drs. Nancy Kopell and Indira Raman), and three from India (Drs. Vijaylakshmi Ravindranath, Chitra Sarkar and Vidita Vaidya) have been chosen by me as representatives and their careers, contributions and views on discrimination against women in science discussed in brief. (This is not to deny outstanding work by others but limitations of space have made this choice necessary.) The factors favouring the blossoming of women in science include encouraging and stimulating parents, a conducive environment at home and mentors. A compelling drive to excel, hard work and sincerity are crucial to success. Nasty forms of experiences demoralise women. Sexual harassment by seniors and colleagues in the laboratory and elsewhere can lead to the victim leaving the field altogether. Discrimination in selection, promotion and publication lower morale and impact output in terms of research and contributions to journals and books. Suggestions made by the five eminent neuroscientists named above to liberate women from such negative behaviour by males are presented. The Indian Women Scientists' Association is playing an important role in helping their members, making their work known to society and generally empowering them. Since unity strengthens, collaborative activities with other similar organisations will augment efficacy. One such organisation is the much older Association of Medical Women of India.

Dr John McLennan MD (Aberdeen), FRCP (Lond) (1801-1874) and the Medical School of Bombay that failed.

In 1826, Dr John McLennan was asked by Governor Mounstuart Elphinstone of Bombay to set up the first school to teach modern medicine to Indian citizens. He was expected to create textbooks on a variety of subjects in local languages and teach medicine to poorly educated students in their native tongues. Despite his valiant efforts, the school was deemed a failure and was abolished by the Government in 1832. Sir Robert Grant, appointed Governor of Bombay in 1835, analysed records pertaining to this medical school and concluded that the school failed since Dr McLennan was not provided the assistance he needed and as his suggestions for access to a hospital to teach medicine were not heeded. Dr McLennan provided able support to Dr Charles Morehead on his appointment as Principal and Professor of Medicine at the newly created Grant Medical College in Bombay in 1845. Dr Morehead dedicated his classic 'Clinical researches on diseases in India' to Dr McLennan. Dr McLennan headed the Board of Examiners created to assess the competence of the first batch of medical students emerging from this College. The system of evaluation set up by him remains admirable. Dr McLennan retired from service as Physician-General, full of honours.