[Downloaded free from http://www.neurologyindia.com on Wednesday, June 03, 2015, IP: 27.5.193.

59]

Neurology India Free full text at

www.neurologyindia.com and www.bioline.org.br/ni

July-September, 2003 CONTENTS Vol. 51 Issue 3

Special Article

Medical ethics in the Neurosciences

S. K. Pandya ................. 317

Review Articles

Neuronal stem cells

D. Joshi, M. Behari ................. 323

Intraoperative MRI in neurosurgery: Technical overkill or the future of brain surgery?

V. Seifert ................. 329

Technical Article

Intracranial pressure monitoring in a resource-constrained environment:

A technical note
M. Joseph ................. 333

Original Articles

Diagnostic validity of the Ki-67 labeling index using the MIB-1 monoclonal
antibody in the grading of meningiomas
A. Devaprasath, G. Chacko ................. 336

Clinical signs as a guide for performing HSV-PCR in correct diagnosis of herpes

simplex virus encephalitis
B. B. Abbas, A. Abdolvahab, Y. P. Gholamali, B. Roshanak, R. Mahmood ................. 341

Outcome prediction model for severe diffuse brain injuries: Development

and evaluation
S. V. Pillai, V. R. S. Kolluri, S. S. Praharaj ................. 345

Effect of mannitol in experimental spinal cord injury: An ultrastructural and

electrophysiological study
A. Baysefer, E. Erdogan, S. Kahraman, Y. Izci, C. Korkmaz, I. Solmaz, U. H. Ulas,
C. Ozogul, E. Timurkaynak ................. 350

Effect of losartan on albuminuria, peripheral and autonomic neuropathy in

normotensive microalbuminuric type 2 diabetics
S. Kubba, S. K. Agarwal, A. Prakash, V. Puri, R. Babbar, S. Anuradha ................. 355

A study of epilepsy-related psychosis

A. K. Roy, S. V. Rajesh, N. Iby, J. M. Jose, G. R. K. Sarma ................. 359

Evaluation of nimodipine in the treatment of severe diffuse head injury: A double-

blind placebo-controlled trial
S. V. Pillai, V. R. S. Kolluri, A. Mohanty, B. A. Chandramouli ................. 361

Neurology India July-September 2003 Vol 51 Issue 3 313

[Downloaded free from http://www.neurologyindia.com on Wednesday, June 03, 2015, IP: 27.5.193.59]

Neurology India Free full text at

www.neurologyindia.com and www.bioline.org.br/ni

Jul y-September, 2003 C O N T E N T S (Contd.) Vol. 51 Issue 3

Cryptococcal infection in patients with clinically diagnosed meningitis in a tertiary

care center
K. N. Prasad, J. Agarwal, V. L. Nag, A. K. Verma, A. K. Dixit, A. Ayyagari ................. 364

Re-evaluation of reading frame-shift hypothesis in Duchenne and Becker

muscular dystrophy
G. S. Pandey, A. Kesari, M. Mukherjee, R. D. Mittal, B. Mittal ................. 367

Venous air embolism: Does the site of embolism influence the hemodynamic changes?
P. Bithal, H. H. Dash, N. Vishnoi, A. Chaturvedi ................. 370

Hemangioblastoma: A study of radiopathologic correlation

C. Sundaram, S. Rammurti, J. J. M. Reddy, V. S. S. V. Prasad, A. K. Purohit ................. 373

Case Reports

Two cases of neuro-Behçet’s disease mimicking cerebral tumor

S. Tuzgen, A. H. Kaya, D. Erdincler, S. A. Oguzoglu, O. Ulu, S. Saip ................. 376

Choroid plexus papilloma of the posterior third ventricle during infancy & childhood:
Report of two cases with management morbidities
S. J. Pawar, R. R. Sharma, A. K. Mahapatra, S. D. Lad, M. M. Musa ................. 379

Sporadic variety of pallido-pyramidal syndrome

J. Kalita, U. K. Misra, B. K. Das ................. 383

X-linked Charcot-Marie-Tooth disease with myokymia: Report of a family

A. Chakravarty, B. Ghosh, S. Sengupta, S. Mukhopadhyay ................. 385

A patient with reversible pupil-sparing Weber’s syndrome

U. Umasankar, F. U. Huwez ................. 388

Delayed post-surgical development of dural arteriovenous fistula after cervical

meningocele repair
T. Flannery, M. H. Tan, P. Flynn, K. A. Choudhari ................. 390

X-linked lissencephaly in an Indian family

S. Panda, M. Tripathi, S. Jain, P. Sharma ................. 392

Isolated fourth ventricular cysticercus cyst: MR imaging in 4 cases with short

literature review
S. Singh, S. V. Gibikote, N. K. Shyamkumar ................. 394

Hemiplegia: An initial manifestation of Japanese encephalitis

A. Nalini, G. R. Arunodaya, A. B. Taly, H. S. Swamy, M. K. Vasudev ................. 397

Herpes simplex encephalitis: Some interesting presentations

S. Jha, M. Jose, V. Kumar ................. 399

Cerebrotendinous xanthomatosis: Neuroimaging findings in two siblings from an

Indian family
S. B. Gaikwad, A. Garg, N. K Mishra, V. Gupt a, A. Srivastava, C. Sarkar ................. 401

314 Neurology India July-September 2003 Vol 51 Issue 3

[ D o w n l o a d e d f r e e f r o m h t

Neurology India Free full text at

www.neurologyindia.com and www.bioline.org.br/ni

Jul y-September, 2003 C O N T E N T S (Contd.) Vol. 51 Issue 3

Isolated ring-enhancing lesion of the brainstem in a patient with cyanotic heart

disease: Role of stereotactic intervention
R. K. Moorthy, V. Rajshekhar ................. 404

Suprasellar arachnoid cyst presenting with bobble-head doll movements: A report

of 3 cases
K. I. Desai, T. D. Nadkarni, D. Muzumdar, A. Goel ................. 407

Short Reports

Successful treatment of intrathecal morphine overdose

A. Yílmaz, A. Sögüt,
r
M. Kílínç, A. G. Sögüt
r
................. 410

Unusual self-inflicted penetrating craniocerebral injury by a nail

S. N. Shenoy, A. Raja ................. 411

Juvenile amyotrophic lateral sclerosis with unusual presentation: A case report

A. Panagariya, A. Garg, B. Sharma ................. 413

Functional recovery in ischemic stroke

M. M. Paithankar, R. D. Dabhi ................. 414

Temporal bone carcinoma with intradural extension

A. K. Khan, S. Deb, D. K. Ray ................. 416

Merosin negative congenital muscular dystrophy: A short report

A. M. Ralte, M. C. Sharma, S. Gulati, M. Das, C. Sarkar ................. 417

Subdural hemorrhage associated with falcine meningioma

A. Goyal, A. K. Singh, S. Kumar, V. Gupta, D. Singh ................. 419

Intravenous sodium valproate in status epilepticus

S. Jha, M. Jose, R. Patel ................. 421

Intracranial aneurysms causing spontaneous acute subdural hematoma

S. N. Shenoy, M. G. Kumar, A. Raja ................. 422

Letter to Editor

Focal early onset of delayed radiation encephalopathy with brainstem signs ................. 425

An early and isolated origin of the angular artery from the middle cerebral artery ................. 425

Anticonvulsant-hypersensitivity syndrome in a child ................. 427

Prognosis in children with head injury: Inaccuracies in the analysis ................. 427

Non-hypertensive intracerebral hemorrhage: Some interesting observations ................. 428

Forthcoming Events ................. 429

Instructions for Contributors ................. 430

Neurology India July-September 2003 Vol 51 Issue 3 315

[Downloaded free from http://www.neurologyindia.com on Wednesday, June 03, 2015, IP: 27.5.193.59]
Special Article
Medical ethics in the Neurosciences
S. K. Pandya
Jaslok Hospital & Research Centre, Dr. G. V. Deshmukh Marg, Mumbai - 400026, India.
Doctors in India are heirs to a long tradition of ethics from
their own forebears and from those from the West. This pa-
per discusses ethical aspects of topics of relevance to neu-
rological scientists such as brain death, neural transplant
and whole brain transplant. Many other topics such as eth-
ics in research, patients with AIDS, patients in a persistent
vegetative state and euthanasia deserve similar considera-
tion and debate.
Key Words: Ethics, Brain death, Neural transplant.
Introduction
No one disputes that the aims of medicine are to help re-
store health, maintain it and prevent it from deteriorating or
being attacked by disease. Here we consider a few aspects of
current medical practices insofar as they pertain to the nerv-
ous system of man.
Primitive tribal cultures have long recognised the fact that
the head contains the centre of reason and ‘the soul substance
of man’. Excavations of prehistoric burials show that often,
before burying the dead, early man removed the skull, evi-
dently attaching a special spiritual value to it.1
Hippocratic tradition has guided western medicine since the
5th century BC. Each doctor taking the oath undertakes to
‘apply ... measures for the benefit of the sick according to my
ability and judgement; I will keep them from harm and injus-
tice. I will neither give a deadly drug to anybody if asked for
it, nor will I make a suggestion to this effect... In purity and
holiness I will guard my life and my art.’2
In India, the populace at large remains guided by ancient
religious and philosophical doctrines. Indian physicians of the
past remained faithful to the oath of initiation3 administered
by the teacher to every student aspiring to the medical profes-
sion. The oath included the following:
‘Day and night however thou mayest he engaged, thou shalt
endeavour for the relief of patients with all thy heart and soul.
Thou shalt not desert or injure thy patient even for the sake
Sunil K. Pandya
Jaslok Hospital & Research Centre, Dr. G. V. Deshmukh Marg, Mumbai - 400026, India. E-mail: shunil@vsnl.com
Neurology India July-September 2003 Vol 51 Issue 3
of thy life...’
‘Thou shalt renounce all evil desires, anger, greed, passion,
pride, egotism, envy, harshness, meanness, untruth, indolence
and other qualities that bring infamy upon oneself.’
‘Thy preceptor, the poor, the friendly, the travellers, the lowly,
the good and the destitute - those thou shalt treat when they
come to thee like thy own kith and kin and relieve their ail-
ments...’
Ideals were instilled with great care and forethought.
‘As long ago as 1000 BC, Çaraka firmly believed that the
head (sira) was the most important organ of the human body.
In the Vedas the brain is considered to be the centre of the
mind which possesses the highest of all senses. If the brain is
destroyed the limbs are paralysed and death follows.’ 4
The present concept of brain death appears to have been
anticipated in the Vedas. ‘We had a recent discussion with an
Ayurvedic acharya and I was quite surprised to see that the
definition given here today is there in the slokas. They say life
is composed of four components. It is a coordinated activity
of shareer, indra, man and atman of which shareer is the body
we see. Indra does not refer to eyes and ears but the sensation
of sight, hearing and touch and a probably modern interpre-
tation in today’s knowledge would be the areas in the brain
which are responsible for that particular sensation. The con-
tent of consciousness is the man... Atman probably means the
seat of consciousness or pran. The breathing centre or pran
lies in the brainstem and so does the seat of consciousness.
When this is not functioning the patient is dead. Thus the
criteria for brain death have already been described for us
several centuries ago...’5
Ancient Hindu and Buddhist philosophy taught the subju-
gation of the desires of the physical body, emphasising in-
stead the need to concentrate on higher, spiritual matters.
The savant considers the body as a mere container for the
essential atman or soul.6 The shell (for that is what the dead
body, devoid of the atman, constituted) is thus to be treated
with indifference.
‘Hindu philosophers undoubtedly deserve the credit of hav-
ing, though opposed by strong prejudice, entertained sound
317
[Downloaded free from http://www.neurologyindia.com on Wednesday, June 03, 2015, IP: 27.5.193.59]
Pandya SK: Medical ethics in the Neurosciences
and philosophical views respecting uses of the dead to the liv-
ing and were the first scientific cultivators of the most impor-
tant and essential of all the departments of medical knowl-
edge - practical anatomy...’ (Wise quoted by Bhagwat Sinh
Jee7).
A Hindu sage or his Buddhist counterpart would have no
difficulty in permitting the use of any part of his corpse for
beneficial purposes. (See also Crowe et al8).
Jain philosophy took off from Hindu origins. It permitted
an aspirant to embrace ritual death under the following con-
ditions: 1) when one suffers from an incurable disease, 2) when
one encounters severe famine, 3) when one encounters condi-
tions that make the maintenance of one’s spiritual life impos-
sible. (Bhagavati-Aradhana quoted by Settur9) Great philoso-
phers - often termed saints - have embraced ritual death upon
realising the illusive character of the world. Most such deaths
were achieved by fasting, solid foods being abandoned at first
and then liquids as well. The corpse of such an individual was
to be allowed natural decay and destruction rather than dis-
posal through funeral and cremation. Several conclusions were
drawn by survivors from the eventual state of the corpse laid
out in the open. The use of organs from such a body for the
welfare of others would have been applauded.
Christians and Muslims in most countries have agreed to
recognise the concept of brain death and permit organ trans-
plantation from persons whose hearts were still beating.10,11
The governing principle in Judaism8 and the Zoroastrian
faith12 is the supreme importance of preserving life. Both these
religions therefore permit organ transplantation.
Transplantation of tissue from the brain of a dead person,
thus, appears to face no serious religious objection. Trans-
plantation of the whole brain or tissue from a foetus, on the
other hand, appears to require further thought and debate.
Modern doctors are privileged in India. They continue to
command respect from the community, earn handsomely and
play a decisive role in almost all matters pertaining to health
and sickness. Most of our countrymen are, on the other hand,
poor and illiterate. The expected compassion, humaneness and
empathy is, however, lacking in many Indian doctors. The
defence that doctors, being part of society, cannot but be
tainted by the corruption prevalent in the population at large
does not hold. Their high level of education, the codes of ethi-
cal practice inherited from such ancients as Çaraka, Susruta,
Hammurabi and Hippocrates and the examples of the great
doctors of the past should have countered such a tendency.
Great care is needed in introducing concepts and prac-
tices that could form a fertile breeding ground for further
malpractices.
Brain death
Rising costs of care of patients whose hearts and lungs can
be made to function artificially but who stand no chance of
318
meaningful life on account of severe and irreversible damage
to the brain by injury or disease focused attention on this
concept. Legal acceptance of the criteria of brain death, from
1959 onwards in France and shortly thereafter in other coun-
tries, permitted treating physicians to shut off all artificial
means for prolonging the function of the heart and lungs in
patients with brain death, thus reducing wasteful expendi-
ture and ameliorating the agony of surviving relatives.
The need to harvest organs for transplants as soon after
death as possible also triggered changes in the means by which
the diagnosis of death can be made with certainty. Discovery
of the fact that organs harvested whilst they were being
perfused by oxygenated blood led to the formulation of the
concept of brain death and, in turn, the means for making
such a diagnosis.
The earlier notion that death can only be certified after the
total and permanent cessation of all the vital functions, exem-
plified by cessation of the heart beat and respiration has thus
given way, to the certification of death on the basis of com-
plete and irreversible cessation of brain function even though
the heart and lungs continue to function. This change is based
on the fact that the essence of a human being lies in the brain.
Death of the brain is inevitably followed by death of the body.
The rest of the body, minus the brain, has no independent
existence.
Once the concept of brain death was accepted it became nec-
essary to lay down criteria for making this diagnosis. In In-
dia, we have ruled that evidence of death of the brainstem
suffices since it is in the brainstem that the mechanisms for
consciousness, cardiac rhythm, blood pressure, respiration and
other vital functions reside. This diagnosis can be made with-
out recourse to expensive or hard-to-find equipment.
We must add a clause to the above statement. The diagnosis
of brain death in infants and young children must be made
with extreme caution. The developing brain poses extra diffi-
culties in diagnosis because of the fact that systems are still
in the process of development. We cannot certify brain death
or brainstem death in children under the age of three years.
The tests required to make a diagnosis of brainstem death
are based on clinical examination. It is mandatory that such a
diagnosis be made by two independent registered medical prac-
titioners not connected with any transplant program. In prin-
ciple, it should be possible to arrive at a diagnosis anywhere
in the country - metropolis, town or village.
The education of all our doctors legally empowered to make
a diagnosis of death (modern medicine, ayurveda, homeopa-
thy, unani and other forms of practice) on the means for mak-
ing of such diagnosis is vital.
The diagnosis of brain death, however, becomes truly rel-
evant only in a setting where the patient is being monitored,
is on a respirator and is being considered as a potential donor
of organs. Such a situation only exists in sophisticated hospi-
tals in towns and cities.
Neurology India July-September 2003 Vol 51 Issue 3
[Downloaded free from http://www.neurologyindia.com on Wednesday, June 03, 2015, IP: 27.5.193.59]
Our experience with renal transplants on payment suggests
the need for caution in the diagnosis of brain death. It will be
necessary to monitor such diagnoses for a long time. This will
not be an easy task. ‘There will not be many problems is state
run hospitals where the criteria for brain death will be strictly
fulfilled. The problems will be in the five-star hospitals or big
nursing homes. Who is going to audit brain death in these places
where they have rich customers waiting for transplantation?’13
Should the term ‘brain death’ be replaced by ‘death’?
There is often grave confusion in the minds of relatives and
friends who are told that their patient has suffered brain death.
They look at the monitor and see the stable pattern of the
electrocardiogram and are unable to reconcile it with what
they have just been told. Almost as though they were mesmer-
ised by the graph on the screen, they continue to harbour the
hope that if the doctors strive a little more, their patient may
recover.
This has led most hospitals and clinics to refrain from dis-
continuing all life support systems despite the diagnosis of
brain death for fear of being sued for murder or malpractice.
The dead patient remains on the ventilator. Drugs to prop up
the blood pressure continue to flow into the body. The family
continues to pay huge sums for several days till the heart comes
to a permanent halt. Their agony is prolonged.
This is a waste. Another patient, whose life may be saved by
treatment in the intensive care unit, cannot be admitted as
this bed remains occupied. Doctors and nursing staff are de-
moralised.
This dilemma has led to the suggestion that we abandon the
term ‘brain death’ which leads the lay person to suppose that
there are different forms of death, ‘brain death’ being inter-
mediate to ‘true death’. The criteria for brain death should
henceforth be publicly proclaimed and legally accepted as the
criteria for death even when organ transplantation is not un-
der consideration. Once this is done, the diagnosis can be fol-
lowed by rapid removal of all life support systems as in the
case of the patient where the heart has permanently stopped
beating.
Removal of life support systems after brain death
The Transplantation of Human Organs Act (1994) passed
by Parliament in India lays down the criteria for brain death
in the context of organ transplantation. The British criteria
(on which our Act is based) clearly state: ‘The medical officer
will speak to the relatives and announce the death. The time
of death is recorded as the time when the final test to fulfil the
criteria for brainstem death was satisfied.’ We need either a
similar specification in our own Act or, better still, a separate
statute defining the new criteria for the diagnosis of death.
Till this happens, Sethi and Sethi’s suggestion14 can be fol-
lowed. In the case Dority versus Superior Court of San
Bernardino County, USA (1983), the court ruled: ‘Brain activ-
Neurology India July-September 2003 Vol 51 Issue 3
Pandya SK: Medical ethics in the Neurosciences
ity is a necessary condition to legal personhood and perhaps
with the exception of the foetus, it is a sufficient condition for
legal personhood… Once brain death has been determined…
no criminal or civil liability will result from disconnecting the
life support devices.’ Should there be a legal query, this case
can be quoted in defence of removal of life support systems
once the patient has been shown to be brain dead.
Neural transplant
General principles
The basic requirements for the performance of any surgical
operation hold.
1. The recipient (or, when the patient is a minor or is non
compos mentis, a legally responsible relative) and the do-
nor (or, when the patient is non compos mentis, a legally
responsible relative) must give willing and informed con-
sent for the procedure.
2. The indications for surgery must be in conformity with
internationally accepted criteria and there must be a rea-
sonable chance of success from the operation. The ben-
efits must outweigh the risks to the recipient.
3. The donor should suffer no harm.
4. The sur geon and the entire transplant team must possess
all that is needed for a successful outcome - expertise, tech-
nical excellence, equipment and ancillaries.
5. All the necessary precautions must be taken to assure a
successful outcome and prevent complications. The devel-
opment of AIDS in recipients of renal transplants make
this all the more important. Since neural tissue used for
transplant could harbour a slow virus, every effort will have
to be made to ensure that the presence of such organisms
has been excluded.
6. Trade in human tissues is contrary to the respect and dig-
nity of the human body. Only those who need such a gift
should receive it rather than only those who can afford it.15
Autografts of neural tissue
No ethical principle is transgressed by such an operation.
As pointed out by Msgr. Cordeiro,16 sacrifice of part of the
human body in the interest of the whole person or that of such
vital organs as the brain or spinal cord has worldwide ethical
sanction.
Heterograft of neural tissue
Heterograft from cadavers, at present unsuited for neural
transplant, will pose no ethical problem provided the opera-
tion has been carried out bearing the general principles out-
lined above in mind and brain death in the donor has been
diagnosed ethically.
Heterograft from live donors will, even more so than in the
319
[Downloaded free from http://www.neurologyindia.com on Wednesday, June 03, 2015, IP: 27.5.193.59]
Pandya SK: Medical ethics in the Neurosciences
case of renal transplant, pose major ethical problems.
Clear and unambiguous guidelines are needed regarding
indications and contra-indications for such procedures. The
indications must confirm that the disease can be cured or al-
leviated only by a transplant. The donor must be guaranteed
that no harm will occur to the functions of his own mind and
brain. The postoperative states of donor and recipient must
be closely monitored along strictly scientific lines on a long
term basis.
The extensive and unscrupulous commerce in kidneys warns
us of malpractices to come. Dealing, as we are, with two hu-
man brains, it is essential that we ensure total honesty, fairplay
and the highest standards from all concerned. Under prevail-
ing circumstances, this may be very difficult in many coun-
tries including India.
Use of foetal neural tissue as transplant
Tandon17 pointed out that questions on whether or not it is
ethical to use foetal neural tissue as transplants have arisen
because the foetus is, in the eyes of the law, a person in its
own right whilst in the maternal womb.
When, however, it is proved that use of tissue from a foetus
aborted for other reasons can alleviate suffering, restore nor-
malcy or help in any other way a suffering human being, it is
difficult to find fault with such usage, especially when no other
means is available for such relief or cure. The foetus, incapa-
ble of independent existence outside the maternal womb, is
dead on abortion or soon thereafter. The use of tissue from
other dead individuals - heart, heart-lungs, kidneys, liver, pan-
creas, cornea, bone, dura mater... has gained the approval of
the law, the medical profession and society at large. There
can be no scientific reason to prohibit the similar use of foetal
tissue.
Having said this, it is necessary to consider purely ethical
and theological objections.
The permission for abortion granted by law in some coun-
tries (including India) ignores the status of an embryo as an
individual. To assert that the use of tissue from a foetus aborted
in accordance with the law of the land is permissible is to
derive ethical approval from legal sanction. This is not in keep-
ing with the principles of ethics which lie on a plane higher
than those of law.
The church forbids removal of neural tissue from a foetus
until it is brain dead.16 Since brain death in a foetus can only
be determined with great difficulty, if we are to accept the
church’s verdict, we shall have to forbid foetal transplants.
Society at large will have to decide upon the practice to be
followed in such cases.
The foetus nearing term, capable of independent survival
outside the maternal womb, cannot be placed in the category
discussed above. Every effort must be made to ensure its sur-
vival. Removal of neural tissue for transplant can only be con-
320
sidered after brain death is established with certainty in such
a foetus.
Present fears centre around the possibility of abortions be-
ing carried out principally or solely for the purpose of obtain-
ing neural tissue for transplantation. That such fears do not
belong to the realm of fantasy is clear from the fact that moth-
ers have become pregnant simply in order to obtain an organ
(such as the kidney) or tissue (such as bone marrow) from the
newborn child for use in an ailing sibling whose life depends
on obtaining such a graft. (In the available examples, the do-
nor has been incorporated into the family with affection and
gratitude).
Ethical principles cannot sanction the sacrifice of a foetus
simply because a sibling needs neural tissue as transplant.
Great caution will be necessary in the legal sanction of the
use of foetal neural tissue for transplantation. The principles
under which such transplants can be permitted may emerge
after much serious debate and must win universal approval.
The guidelines provided by the British Medical Association8
may serve as a model. Ensuring that no unethical or illegal
transplantation is carried out is, however, likely to prove diffi-
cult especially in countries such as India.
Andrews 15 suggests development of foetal cell lines from spon-
taneously aborted foetuses so that a large quantity of trans-
plantable tissue is obtained from a very small source. Such
tissue could be used for transplantation without the breach of
ethical or legal principles.
Whole brain transplant
At present this is in the realm of science fiction. Even so, it
must be considered for in the field of medicine and biology, all
too often, a procedure proclaimed impossible has been put
into operation shortly after the proclamation.
Should they come to pass, whole brain transplants will bris-
tle with ethical dilemmas. Since the brain is the organ for
thought, perception, imagination, emotion and, indeed, all
activities of the mind and intellect, the fundamental question
is who is the donor and who the recipient. Here, the organ
represents the individual not the insensate body that will house
the organ. If, the brain of A is transplanted into the body of
B, does B now assume A’s identity? Does B’s family, property
and other worldly possessions now belong to A? And what of
A’s family, property? ‘Is it right for a person who has led a ...
righteous life to have the mind of ...a criminal foisted upon
him?’12 What will be the criteria for the selection of the person
owning the brain to be transplanted and those for the body
that will receive it?
Whole brain transplants will also face considerable opposi-
tion from the theologians.16,12 The very idea of transplanta-
tion of the mind and soul (if we accept the belief of many
scientists that the soul resides in the brain) of one person into
the body of another is anathema to them. Even if you do feel
Neurology India July-September 2003 Vol 51 Issue 3
[Downloaded free from http://www.neurologyindia.com on Wednesday, June 03, 2015, IP: 27.5.193.59]
that the soul resides elsewhere in the body, there are major
obstacles, at least in the Zoroastrian faith. ‘It is not only un-
ethical but also against the cosmic laws of nature to try and
interfere fundamentally with the soul of a person by giving
him a mind which is different from the one he was born with...
A brain transplant would result in a soul developing a mixed
identity.’12 Scientists may find themselves out of their depths
here. How does one identify the soul? How does one ascertain
the identity (leave alone a mixed identity) of the soul?
Prime requisites for the establishment of
neural transplants in humans in India
1. Cultivation of a sense of morality in the medical profession.
2. Carefully and painstakingly evolved legislation on neural
transplants. Such legislation should cover criteria for the
selection of the recipient (including the establishment of
computerised state and national registers and criteria on
which priority of selection of the recipient must be based),
criteria for selection of the donor, consent to be given by
the donor or his family, basis for the computation of costs
of transplantation and criteria for the recognition of cen-
tres for such surgery.
3. Where a live donor is involved, ample checks should be
built in to ensure that he undergoes no harm as a conse-
quence of his donation.
4. A well-established mechanism for checking the working of
transplant centres within a given state or the country at
large. Ordinarily this task could have been delegated to
the medical councils but their track record does not justify
faith in their ability to do justice to such a task.
5. Means for the dispensation of swift justice in case of mal-
practice.
6. Periodic state or national conferences where the results of
each transplant (including detailed and well-documented
follow-up findings) are reviewed and analysed.
Relevance of neural transplant programs in
poor countries such as India
The ethics of massive expenditure on transplant programs
in a country where measures to prevent disease and malnutri-
tion are inadequate must also be addressed. As Dr. S.
Mukherjee put it, ‘In our country we do not immunize all our
children, we do not give full meals to all our people and we do
not provide clean drinking water for all our people. These are
the real problems, while we are sitting in an air-conditioned
room and talking about transplants which cost crores of ru-
pees.18
It is also important to ensure that transplant programs are
not carried out merely in an attempt at medical adventurism.
Callahan’s cautionary note is relevant: ‘I have before my mind’s
eye a future health care system that seeks not constantly to
Neurology India July-September 2003 Vol 51 Issue 3
Pandya SK: Medical ethics in the Neurosciences
conquer all disease and extend all life but which seeks instead
to enhance the quality of life; which seeks not always to over-
come the failings and decline of the body but which helps peo-
ple better accept and cope with them; which tries to keep in
view that health is a means to a decent life, not a value in its
own right.’19
These difficulties notwithstanding, a case can be made for
the development of the technology for successful transplanta-
tion at a few, very carefully planned and strategically located
centres in India (perhaps one each for the north, east, south
and west of the country) after the value of such transplants
has been unequivocally established internationally. It may
become necessary for the rich to subsidise transplants for the
poor in order to ensure that the facilities are intended for all
those absolutely in need and not only for those who have the
money for the procedure.
We must, at the same time, acknowledge the beguiling, al-
most insuperable temptations that this very expensive kind
of surgery will spawn. The sums involved make it unlikely
that doctors will remain content with the establishment of a
single transplant centre in each geographical region. The
greed for lucre, power and political influence will force deci-
sions on grounds other than logic and rationality. We have,
unfortunately, far too many examples of such practices in
the setting up of private medical colleges and centres hous-
ing very expensive tools for investigation, to give but two ex-
amples.
Epilogue
This essay has dealt with just a few aspects of ethics in the
clinical neurosciences. There are many other subjects deserv-
ing discussion and debate: ethics in neuroscientific research,
patients with HIV infection and those with AIDS, patients in
a persistent vegetative state, euthanasia…
It is also relevant to rephrase Pilate’s query and ask ‘What
is ethics?’ for ethical norms undergo changes based on geog-
raphy, culture, current terms of reference and social norms.
Abortion was bitterly condemned and abortionists convicted
of criminal action the world over till factors such as overpopu-
lation compelled countries such as India to legalise the sacri-
fice of the unborn child.
Some ethical principles are likely to prevail but others may
give way. Our discussion must, therefore, be considered only
as part of a continuing series. Our conclusions must provide
room for change when needed.
Even given unanimity on ethical principles and effective leg-
islation, can we enforce practice based on them? Present ex-
perience in India does not justify optimism.
Acknowledgements
Dr. Eustace J. deSouza kindly gifted me a copy of the thought provoking book on the
321
[Downloaded free from http://www.neurologyindia.com on Wednesday, June 03, 2015, IP: 27.5.193.59]
Pandya SK: Medical ethics in the Neurosciences
subject of brain transplantation from which I have drawn freely.
References
1. Gelfand M. Philosophy and ethics of medicine. Edinburgh: E & S Livingstone
Ltd; 1968.
2. Amnesty International. Ethical codes and declarations relevant to the health
professions. 2nd edn. London: Amnesty International; 1985.
3. Mehta PM. The oath of initiation. The Çaraka Samhita. Jamnagar, India: Shree
Gulabkunverba Ayurvedic Society. 1949. Vol. 1. pp. 162-4.
4. Vas CJ, deSouza EJ, editors. Brain transplantation. Ethical concerns. Report
of a consultation workshop. Bombay: F.I.A.M.C. Bio-medical Ethics Centre.
1989.
5. Anand Lt. Col. A. C. Discussion. In: Pande GK, Patnaik PK, Gupta S, Sahni P
(Compilers): Brain death and organ transplantation in India. P roceedings of a
workshop held at Calcutta on 10 June 1990. New Delhi: The National Medical
Journal of India; 1990.
6. Pandya SK. Hindu philosophy on pain: an outline. Acta Neurochirur gica. Sup-
plement 1987;38:136-46.
7. Bhagwat Sinh Jee. Aryan medical science - a short history. Delhi: Rare Re-
prints; 1981. pp. 179.
8. Crowe AJ, Fortes-Mayer KD, Horner JS, Macara AW, McKechnie S, Wilks M.
Philosophy & practice of medical ethics. London: British Medical Association; 1988.
9. Settur S. Pursuing death. Karnatak University, Dharwad: Institute of Indian
Art History: 1990.
10. Nundy S. Ethical problems in organ transplantation. In: Pande GK, Patnaik
PK, Gupta S, Sahni P (Compilers). Brain death and organ transplantation in
India. Proceedings of a workshop held at Calcutta on 10 June 1990. New Delhi:
322
The National Medical Journal of India; 1990.
11. Vas CJ. Definition of brain death and consequences of recognizing brain death.
In: Pande GK, Patnaik PK, Gupta S, Sahni P (Compilers): Brain death and or-
gan transplantation in India. Proceedings of a workshop held at Calcutta on 10
June 1990. New Delhi: The National Medical Journal of India; 1990. pp. 3-8.
12. Bharucha JB. R eligious perspectives. In: Vas CJ, deSouza EJ, editors. Brain
transplantation. Ethical concerns. Report of a consultation workshop. Bom-
bay: F.I.A.M.C. Bio -medical Ethics Centre; 1989.
13. Mazumdar Guha. Discussion. In: Pande GK, Patnaik PK, Gupta S, Sahni P
(Compilers). Brain death and organ transplantation in India. P roceedings of a
workshop held at Calcutta on 10 June 1990. New Delhi: The National Medical
Journal of India; 1990.
14. Sethi NK, Sethi PK. Brain death: implications in India. JAPI J Assoc Physi-
cians India 2003;51:910-1.
15. Andrews K. The ethics of human brain transplantation. In: Vas CJ, deSouza
EJ, editors. Brain transplantation. Ethical concerns. Report of a consultation
workshop. Bombay: FIAMC Bio -medical Ethics Centre; 1989.
16. Cordeiro AF. Religious perspectives. In: Vas CJ, deSouza EJ, editors. Brain
transplantation. Ethical concerns. Report of a consultation workshop. Bom-
bay: FIAMC Bio-medical Ethics Centre; 1989.
17. Tandon PN. Neural transplants: current status. In: Vas CJ, deSouza EJ, edi-
tors. Brain transplantation. Ethical concerns. Report of a consultation work-
shop. Bombay: FIAMC Bio-medical Ethics Centre; 1989.
18. Mukherji S. Discussion In: Nundy S. Ethical problems in organ transplantation.
In: Pande GK, Patnaik PK, Gupta S, Sahni P (Compilers). Brain death and or-
gan transplantation in India. Proceedings of a workshop held at Calcutta on 10
June 1990. New Delhi: The National Medical Journal of India; 1990.
19. Callahan D. What kind of life: the limits of medical progress. Simon and
Schuster, New York: 1990. pp. 318.
Neurology India July-September 2003 Vol 51 Issue 3