Brain Dead

Is a brain dead person dead? The answer is both yes and no and depends upon under which Act you are looking and what actions your legal heirs/family members take once you are declared brain dead. How is it possible that the answer is both yes and no? The dilemma lies in the way the death is defined in the two acts, that is Registration of Birth and Death Act 1969 and the Transplantation of Human Organs Act 1994 and this puts the medical fraternity in dilemma and here again they are faced by devil’s choice, unless the legal heirs/family members help them out.

Death is defined in the Registration of Birth and Death (RBDA) Act 1969 as “The permanent disappearance of all evidence of life after live birth has taken place”. The mention of the word all, evidence of life excludes brain death. Therefore even if the doctors issue a death certificate stating brain death as a cause, which normally they will not do, then the death cannot be registered as death under this act. Hence no death certificate can be issued, implying that even though the person is dead and cremated but he is still alive legally.

Brain dead has only been defined in the Transplantation of Human Organs (THO) act 1994 only in connection with human organ donation and has led to the certification being mostly viewed as a procedure. If the legal heirs refuse to donate the organs, this applies even though you may have donated the organs legally as without their permission the donation is not valid unless you have made a living will or what is called Advance Declaration by the Supreme Court. The procedure for the execution of this advance declaration is very lengthy and cumbersome with the judicial magistrate first class being the custodian and executor of the living will and only after recommendation of a medical board as given in the Supreme Court judgement. The act also is not clear as to what will happen if family refuses to donate organs and in that eventuality the doctors will also refuse to switch off the ventilator and support systems fearing legal implications and the cost of treatment will keep rising till death takes place and may lead to a huge bill. Death in THO act is defined as “Permanent disappearance of all evidence of life by reason of brain stem death or in a cardio pulmonary sense at any time after live birth has taken place”. Here brain stem death is defined to mean death and this act will apply only if the legal heirs/family members agree to donate the organs.

Medical fraternity is of the opinion that it is futile intervention once diagnosis of brain dead is made. But it is challenging for a doctor and the family to decide whether to continue life support or not. This is what we often refer to as the devil’s choice, the doctors fearing legal implication and the family worried about the rising cost per day and the bad mouthing by the relatives and friends and social humiliation. The gap between brain death and cardiac death may be days. There is a 10 step procedure to be followed for certifications if the THO act becomes applicable and only if family agrees to donate organs. Conditions are laid down as to when and how the brain death can be declared and the process is to be repeated after an interval of six hours.

Therefore what is needed is that the  procedure needs to be specified under the RBDA 1966 to include brain death as a cause of death along with the procedure to constitute a medical board which will examine the case and conduct tests which can be repeated after 6 hours or as specified and the board will have the power to declare the person brain dead even though the family members have not agreed for organ donation but are unwilling to continue with the life support system due to any reason whatsoever.

Death V/S Brain Death

As per official medial data in India every 20 second a person suffers brain stroke and if medical help is not provided within 4 hrs then it may result in brain death and because of this delay every 2 minutes a person dies.

Registration of Birth and Death Act (RBDA) 1969 defines death as "The permanent disappearance of all evidence of life at any time after live birth has taken place." While the Transplantation of Human Organs (THO) Act 1994 defines death as "Permanent disappearance of all evidence of life, by reason of brain stem death or in a cardio-pulmonary sense at any time after live birth has taken place." Therefore a person who is brain dead under RBDA Act cannot be declared dead unless his organs are donated under THO Act.
It is this difference in definition which creates certain important issues as doctors will refuse to remove the life support ventilator system in case of a brain dead person unless the family agrees to organ donation and the THO Act comes in play. If family refuses to donate the organs then the doctors have no choice but to continue with the life support system thus creating extra financial burden, mental agony and the  extra burden on the already scares ventilator assisted beds in ICU of hospitals as the gap between a brain death and the cardiac death may be days.
Of course the decision whether to donate organs or not depends on the patient if he has written an advance deceleration or living will or on the family of the patient. Irrespective of whether you have donated your organs in a legal manner or not your legal heirs/family will be asked whether they wish/your organs to be donated or not, unless an advance declaration or living will is produced.

Some Duties of a Citizen

We are very much aware of our fundamental right as given in the constitution of India and on a slightest pretext rush to Supreme Court for their enforcement and to guard against their dilution. TV debates are held and hotly contested, interviews are given, press conferences are held and it is said that democracy is in danger.But I have not seen or heard a single debate or press conference held to enlighten the citizens about their duties and responsibilities as an Indian citizen as given in the article 51A of constitution of India. With rights comes the responsibility and accountability and all are inseparable. One is incomplete without the other.
Duties of a citizen:-
It is the duty of every citizen of India to report to the police, if they have witnessed or they have any information about the following offences made punishable under the Law as envisaged in the Article 51-A of the constitution of India :-
• Offences against the State.
• Offences against the public tranquillity.
• Offences relating to adulteration of food and drugs etc.
• Offences affecting life.
• Offences relating to kidnapping for ransom.
• Offences of theft after preparation made for causing death, hurt or restraint in order to the committing of the theft.
• Offences of robbery and dacoity.
• Offences relating to Criminal Breach of Trust by Public servant.
• Offences of mischief against property.
• Offences of house or lurking house trespass as specified in Sections 449 and 450 Indian Penal code.
• Offences relating to currency notes and bank notes.
Besides the above, it is also the duty of the citizens to co-operate with the Police in investigation of the case at the time of conducting search and preparing seizure list, or inquest proceedings in the interest of furthering .

Devil's Choice & Other Dilemmas

Our epic Mahabharata describes an alternative, where Vidur said that “It is better to sacrifice one person in order to save the village”.

At that time he was referring to the devil’s alternative or devil’s choice of choosing the lesser evil which later on authors and philosophers have used to describe various situations.

Health professionals do not always have the luxury of making the right choices. The choice may at one extreme be - whether to keep the person on life support system when they know he is not going to live or allow him to die. In this case they end up being criticized on both choices. They are blamed for not providing medical care till the last moment and are also often accused of inflating medical bills due to prolonged use of life support system. The Devil’s choice is a metaphor used to describe medical choices that arise in circumstances where all the available options are both unwanted perverse.

When Texas Lt. Governor Dan Patrick suggested that the elderly should be willing to die in order to save the young, it caused a big uproar and public condemnation. Was he was just using a trade off between saving people from virus but condemning those who survive to a life of hunger and poverty  or he was just referring to the dilemma that if there is a bed in an ICU which can be given to the old or to a young then what would you choose? What was his intent?

 The answers are not simple.

 Frederick Forsyth in 1975 wrote an un-filmed screenplay titled “No Alternative” and later on in 1979 used the idea to write his famous book “The Devil’s Alternative” which simply means that irrespective of what choice you make blood is going to be spilled.

Decision makers have often used this alternative to choose the alternative with lesser evil. The doctors try to avoid this by just accepting the first come first served basis formulae. We have often used it in different forms, - Survival of the fittest or it is natural law or you are between devil and deep sea or out of frying pan into fire, etc.

Corporate strategists and war planners have used a variation of this called Devil’s Math to describe a situation where a decision requires harming a small group or an individual to save larger group. It is often used in corporate layoffs or in any situation where you are balancing the need of many against the need of a few. It just means that there are no good choices and you are doing something evil to a small group in order to prevent a greater evil from happening. The bombing of Hiroshima and Nagasaki was justified with this devil’s math.

There are many more such dilemmas that have been used often in books and films. ‘Sophie’s choice’ a film in 1982 based on the novel by William Styron (published in 1979) refers to the difficult decision making situation that a person finds himself in where no outcome is preferable over the other. This can mean either that both outcomes are equally desirable or both are equally undesirable. The choices could be whether one wants clean, or lower green house emission at global level.

In Cornelian Dilemma, named after Pierre Cornelia, a French dramatist, a situation is taken where a person must choose between two courses of action that either will have a harmful effect on themselves or others. A migrant laborer stuck in another state during lock down is faced with this dilemma.

In Hobson's Choice, even though it appears to be a free choice but actually it is not so, the choice is simple “‘take it or leave it”. The choice is between taking things that are offered and nothing at all.

All the above theories refer to decision making under difficult situations.

There are no ready made or easy answers in this situation as in the present case of extended lock down due to the Corona Virus. There are going to be problems whether the lock down is extended or not extended.  Countries will have to take a long time to overcome all the effects. But here again the Indian Government probably chose the lesser evil and the other countries used their own wisdom and assessment to choose lesser evils too.

As I said, there are no clear cut answers. There are no evident solutions. It’s all the math of trade offs between the available choices.

Operation Camouflage by Amit Sidham

Just finished reading the book Operation Camouflage by Amit Sidana.  This is the first book I have read from Amit and I thoroughly enjoyed reading it. I picked up the book thinking it will be another spy or some other kind of thriller and will do for a light reading. But when I started reading the book I realized that it is not one of the other suspense and thriller book but one which talks about serious issues of environment degradation and the welfare of all the species that live on this earth and about our ancient knowledge of yoga, Ayurveda and the concept of holistic healing but camouflaged in a fictional story. Not only this but  it also has some out of box thinking ideas about the corporate word and lessons which we can learn to improve our corporate culture which is synonymous with the welfare and well being of its employees.

The main character of the book Adiyta meaning sun is one of the four other characters of the book who together derived their names and signifies the Panch Tatva of the nature, viz, air, water, fire, earth and the ether (Space) and referred in the book as Panch Bhoot.

Of course it is a work of fiction about the crusade launched by these five to protect the environment and the species that live on this earth. The novel is very gripping and the concepts given by Adiya about sustaining the environment and looking after the welfare of the inhabitants of this planet are worth discussing. These out of box thinking ideas can also form a basis for developing a new corporate culture based on Indian ethos and philosophy. The concept that a homo sapiens is also one of the species that inhabit this planet and hence the treatment of all the species for various diseases can be done by mastering the principles of Ayurveda and the techniques as given there. These concepts brought  my mind to another book by Dharamdas  on technological advances in Ancient India ,where he has compiled the book based on the records of the reports submitted and available in British Archives by the British travelers, intellectual in India on their witnessing a replacement of broken nose, making ice in 17th century, steel making, extraction of magnesium and the role played by Brahmin’s of Varanasi  in vaccinating with live germ to protect the children of Bihar and West Bengal them from kala azhar.

I strongly recommend reading this book and I am eagerly awaiting for his next book and some new out of box ideas on corporate culture and our ancient but otherwise lost or gradually loosing knowledge on Ayurveda and its techniques.