Kerala is moving towards the mandatory certification of brain death at intensive care units in all medical facilities in the State, irrespective of whether organ donation takes place or not.
What is brain death?
- Brain death is the complete loss of brain function.
- When someone is brain dead, it means that the brain is no longer working in any capacity and never will again.
- Other organs, such as the heart, kidneys or liver, can still work for a short time if the breathing machine is left in place, but when brain death is declared, it means the person has died.
Current Scenario in India:
- At present, there is lack of clarity on how clinicians should proceed if there is a brain-dead patient in the ICU and the family has refused consent for organ donation.
- In India, brain death has been defined only in connection with organ donation, in the Transplantation of Human Organs Act, 1994.
- The Act does not specify whether ventilation and ICU care may be withdrawn if a patient is brain-dead but organ donation has not been proposed.
- Lack of clarity in the law had been posing a lot of problems for clinicians.
What is the Standard practice followed across the globe?
- Once brain death declaration becomes a standard ICU procedure (after performing the first apnea test as specified under the THO Act), treatment can be terminated post discussion with the families.
- Any new therapeutic ventilatory strategies would only be adopted for preserving organs for organ donation, which is the standard practice all over the world.
- The government, after legal consultations, will soon issue executive orders delinking brain death certification and organ donation, so that there is more clarity as to how clinicians should proceed with intensive care unit (ICU) care in the case of a patient who has been declared brain-dead, but whose family has refused consent for organ donation.
- Once brain death is diagnosed as per the existing legal and clinical requirements and the certification process is completed, ICU care will be continued only if organs are to be retrieved for possible donation.
- If organ donation is not a possibility, then all care will be stopped so that the much valuable ICU resources are not wasted and may be utilised for a salvageable person.
- The decisions were taken at a meeting of senior health administrators, transplant surgeons, neurologists, and critical care specialists on developing parameters for universal brain death certification.
Medical body Indian Council for Medical Research (ICMR) develops affordable test kit to diagnose blood disorders.
- The ICMR’s National Institute of Immunohaematology, Mumbai, has developed a cost-effective Point-of-Care (POC) rapid diagnostic test for severe Haemophilia A and Von Willebrand Disease (VWD)
- This is the first in the world POC test for specific diagnosis of any common bleeding disorder.
- Working cost of these kits is less than ₹50 in comparison to existing conventional test for the diseases that costs around ₹4,000 to ₹10,000,
- Patients with severe Haemophilia A or VWD can have life threatening spontaneous or post-traumatic bleeding like brain haemorrhage and gastrointestinal bleed or they may have bleeding into joints or superficial bleeding from the nose or gums.
- Haemophilia is a mostly inherited genetic disorder that impairs the body’s ability to make blood clots, a process needed to stop bleeding.
- This results in people bleeding longer after an injury, easy bruising, and an increased risk of bleeding inside joints or the brain.
- There are two main types of haemophilia: haemophilia A, which occurs due to not enough clotting factor VIII, and haemophilia B, which occurs due to not enough clotting factor IX.
- They are typically inherited from one’s parents through an X chromosome with a non-functional gene.
- Other types include haemophilia C, which occurs due to not enough factor XI, and parahaemophilia, which occurs due to not enough factor V.
- Acquired haemophilia is associated with cancers, autoimmune disorders.
- As haemophilia A and B are both X-linked recessive disorders, females are rarely severely affected.
- Some females with a non-functional gene on one of the X chromosomes may be mildly symptomatic.
- Haemophilia C occurs equally in both sexes
Von Willebrand Disease (VWD):
VWD is a genetic disorder caused by missing or defective Von Willebrand factor (VWF), a clotting protein.
- There is no dearth of conflicts in West Asia. The Israeli-Palestinian conflict has defied resolution for seven decades.
- The fight against the Islamic State and its offshoots in Iraq and Syria has drawn in the U.S., Russia, Iran and Turkey, while the civil war in Yemen has heightened tensions between Saudi Arabia and Iran.
- It is important to note that U.S. President Donald Trump’s announcement of the U.S.’s unilateral withdrawal from the Iran nuclear deal (the Joint Comprehensive Plan of Action, or JCPOA), added to this volatile mix and set into motion a dynamic that is fast approaching crisis point.
The deal at risk:
- The JCPOA was the result of prolonged negotiations between 2013 and 2015 between Iran and P5+1 (China, France, Germany, Russia, U.K., U.S. and the European Union).
- It would not have worked but for the backchannel talks between the U.S. and Iran, quietly brokered by Oman, in an attempt to repair the accumulated mistrust since the 1979 Islamic revolution.
- Further, it is important to note that Barack Obama had described the JCPOA as his greatest diplomatic success as U.S. President.
- Iran was then estimated to be months away from accumulating enough highly enriched uranium to produce one nuclear device.
- The JCPOA obliged Iran to accept constraints on its enrichment programme backed by a highly intrusive inspection regime in return for a partial lifting of economic sanctions.
- Trump had never hidden his dislike for the JCPOA, calling it a “horrible, one-sided deal that should have never, ever been made”. After ranting about it for a year, he finally pulled the plug on it on May 8th 2018.
- Having replaced Rex Tillerson with Mike Pompeo as his Secretary of State, and H.R. McMaster with John Bolton as National Security Adviser in March last year (2018), the decision was easier as both Mr. Pompeo and Mr. Bolton share his extreme views about the JCPOA and the Iranian regime with equal fervour.
- By November 5th, 2018, the U.S. had re-imposed sanctions on Iran that had been eased under the JCPOA.
- The U.S. decision was criticised by all other parties to the JCPOA (including its European allies) because Iran was in compliance with its obligations, as certified by the International Atomic Energy Agency (IAEA).
- The fact that the U.S. unilaterally violated a legally binding (Ch VII) UN Security Council resolution (2231) mattered not an iota.
- Iran declared that it would continue to abide with the restrictions imposed on its nuclear activities under the JCPOA as long as the EU would uphold the promised sanctions relief.
- Trump’s criticism of the JCPOA was that it did nothing to curb Iran’s missile development or its destabilising regional behaviour.
- His primary cheerleaders in denouncing the JCPOA were Saudi Crown Prince Mohammed bin Salman and Israeli Prime Minister Benjamin Netanyahu.
- Although the Europeans shared some of Mr. Trump’s concerns, they unanimously declared that the best way forward was to faithfully implement the JCPOA and then negotiate further.
‘Maximizing pressure’ on Iran:
- In keeping with its strategy of ‘maximum pressure’, on April 8, the U.S. designated the Islamic Revolutionary Guard Corps (IRGC) a foreign terrorist organisation, a move rejected by the U.K. and European allies.
- It is the first time that U.S. has named the military of another country ‘terrorist’.
- It is important to note that given the IRGC’s involvement in large parts of Iranian economy and relations with Hezbollah, the U.S. designation of the IRGC makes it difficult for Iran to get a clean chit from the Financial Action Task Force (FATF) in June.
- Eight countries, including India, were provided a six-month-waiver by the U.S. to continue Iranian oil imports as long as they showed significant reductions. India brought its oil imports down from around 480,000 barrels per day (bpd) to 300,000 bpd. These waivers lapsed on May 2nd, 2019.
- Civilian nuclear cooperation at Bushehr, Arak and Fordaw was being undertaken by Russia, China, France, Germany and the U.K. under a waiver that has been curtailed and now needs to be renewed every 90 days, making things difficult.
- The waiver for shipping out excess heavy water (Iran can keep only 130 MT) and low enriched uranium (Iran can hold 300 kg) has been revoked.
New Sanctions on Iran:
- Over the last year, the U.S. has imposed new sanctions in an attempt to strangle the Iranian economy, leading to heightened tensions.
- In a clear signal, Mr. Bolton announced on May 5th, 2019 that the U.S. was deploying an aircraft-carrier strike group (USS Abraham Lincoln) and a B-52 bomber force to the Persian Gulf “in response to a number of troubling and escalatory indications and warnings”. The new threats have not been elaborated.
- On May 8th, 2019, Iranian President Hassan Rouhani declared that following U.S. announcements, Iran would no longer observe the ceilings of 130 MT of heavy water and 300 kg of low enriched uranium, and excess production would be retained within the country.
- He clarified that “Iran does not want to leave the agreement; today is not the end of the JCPOA”. Given the current rate of heavy water production and uranium enrichment, it is unlikely that the ceilings will be breached. Since Iran is observing the verification arrangements, any increase in production will be monitored by the IAEA.
- Rouhani also announced a window of 60 days for other JCPOA members to make good on their commitment to ensure sanctions relief, failing which Iran could undertake uranium enrichment above 3.67% (a restriction under the JCPOA) and resume construction of Arak heavy water reactor (this was mothballed). This would mean the end of the JCPOA.
- The U.S. responded by announcing additional sanctions on Iran’s industrial metal industry, the second largest export item after oil.
- In addition, a USS Arlington (transporter of amphibious vehicles and aircraft) and a Patriot missile defence battery have also been deployed.
Critical test for the EU:
- Many observers have described Iranian action as a ‘minimalist response’ to ‘maximum pressure’. However, Mr. Rouhani made it clear that the decisive moment would come after 60 days. It is a warning, particularly to the Europeans, that Iranian patience is running out.
- After committing to evolving an arrangement to bypass dollar-based transactions to enable sanctions relief to continue, the EU announced the setting up of the Instrument in Support of Trade Exchanges (INSTEX) on January 31, 2019.
- Promoted by the U.K., France and Germany and based in Paris, it is currently limited to pharmaceuticals, medical equipment, food and agricultural products. Eventually, it is to be extended to third countries and cover oil exports. Iran set up its counterpart body, the Special Trade and Finance Institute (STFI), on April 29th, 2019.
- If EU decision-making is protracted, Iran too is a difficult negotiating partner.
- Trump keeps insisting that the U.S. does not want war and believes that ‘maximum pressure’ will bring Iran back to the negotiating table or even bring about regime change. He says he is waiting for a telephone call from Tehran, ready to negotiate a ‘better deal’. Iranians are a proud people and such a call is not going to come.
- Last year (2018), Iran’s decision to continue observing the JCPOA was based on the idea of outlasting a single-term Trump presidency.
- As a second term for Mr. Trump becomes likely, Iran knows that it needs to develop its nuclear capability beyond the point of no return to ensure regime survival. This is the lesson from North Korea.
- Many in the U.S., as well as Israel and Saudi Arabia, hope that the heightened military pressures will tempt Iran into a provocation which can be used to justify a U.S. military response. If this happens, it will throw the region into prolonged turmoil, unravelling boundaries established nearly a century ago.
- In conclusion, the EU has long wanted to be taken seriously as an independent foreign policy player. Here is its diplomatic moment — can it strengthen INSTEX enough to persuade Iran to stick with the JCPOA, or will it only end up issuing pious calls for restraint all around?
- It is important to note that already wealthy countries have become wealthier and developing countries have been made poorer in relative terms during the past half century.
- India’s GDP growth penalty between 1961 and 2010 is in the order of 31% for the period, whereas Norway gained about 34% on a per capita basis.
- More recently, the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services has reported that, worldwide, the abundance of species has reduced by at least one-fifth, about a million species are under threat of extinction in the next few decades and 85% of wetlands have been lost.
- Unfortunately, none of these stunning scientific findings made banner headlines.
- The Economic Advisory Council to the Prime Minister did not hold an emergency meeting to discuss the loss of economic output because of climate change or the effects from loss of biodiversity in India.
- Moreover, the manifestos of the political parties contesting the Indian general election barely took note of questions relating to climate and environment.
- Instead, critics opine that it is “business as usual” or “life as usual” in the familiar news cycles of bickering and politics.
Instances of collusion:
- What we have, moreover, are numerous instances of elite networks that are taking advantage of the situation to consolidate their control.
- These networks often involve governments actively or quiescently colluding with fossil fuel companies, agro-industrial elites, financial elites and other big businesses that are ignoring climate change and making a fast buck often even from the growing disasters.
- The International Monetary Fund estimates in a recent working paper that fossil fuel subsidies were $4.7 trillion in 2015 and estimated to be $5.2 trillion in 2017.
- It goes on to say that efficient fossil fuel pricing would have reduced global carbon emissions by 28%.
Cases in Point: The Arctic and Mozambique
- The Arctic is melting rapidly and the tenor of the recent discussions among Arctic countries suggests that even as increasing glacier melt is responsible for opening up shipping in the area, superpowers are angling to access wealth from the oil, gas, uranium and precious metals in the region.
- Mozambique recently had two successive intense cyclones, Idai and Kenneth, with widespread devastation.
- As a matter of fact, there have been instances where big oil and energy companies have been eager to tap into Mozambique’s liquid natural gas, with large banks from many countries involved in the financing.
- It is important to note that in 2013, bank loans for $2 billion were guaranteed by the Mozambican government. However, when the government defaulted on its loans and the currency plummeted, it left behind a trail of woes. In essence, the story in Mozambique is of how “corrupt local elites collude with plundering foreign elites” and enrich themselves and their partners, while the people are left to bear the burden of debt.
- Further, while this kind of corruption may not be new, various versions of this are played out in other countries. Governments’ corporate cronies and plundering elites, of course, need not be foreign.
- Environmental laws can be broken by old boys’ networks with impunity as penalties are cancelled by a party in control.
- It is the poorest and those without access to power who become victims of the fallout from these situations.
- Another recent example to be pointed out here is the draft Indian Forest Act of 2019, which enhances the political and police power of the forest department and curtails the rights of millions of forest dwellers.
What the critics say?
- Policies and commitments make it clear that most governments and businesses are not interested in dealing with the climate and ecological crises.
- They will certainly not give these the central attention they deserve in these times of an emergency; they barely even acknowledge them.
- It is important to note that fossil fuel companies and politicians have known about climate change for at least 30 years. They have funded misinformation regarding climate directly, taking lessons from tobacco companies that propagated lies for decades about cigarettes being safe.
- The documentary film Merchants of Doubt describes how a handful of scientists have obscured the truth on global warming so that business profits can continue to flow.
- Further, the fossil fuel industry has also funded politicians, so their words and laws are already bought.
Responses to the “planet emergency”: People’s Movements
- What we are currently witnessing is a large-scale movement for “planet emergency”, climate and ecology.
- There have been non-violent civil disobedience movements such as that started by Greta Thunberg. Greta Thunberg has been leading a non-violent civil disobedience movement among school-going children, while Extinction Rebellion has been organising “die-ins” in many parts of Europe and now in Asia. Experts opine that these non-violent civil disobedience movements are just what is needed and it is indeed inspiring to see children and grandparents protest together.
- It is important to note that people’s movements, whether made up of students or adults, cannot be ignored for long and governments will have to pay attention.
- The atmosphere now has concentrations of over 415 parts per million (ppm) of carbon dioxide, compared to 280 ppm in pre-industrial times.
- The only solutions that governments and business are looking for are those that enable them to carry on as before.
- However, the planet is well past that point where small fixes can help take us on a long path to zero carbon earth.
- We are now at a stage where we need major overhaul of our lifestyles and patterns of consumption.
- The U.K. Parliament became the first recently to declare a climate emergency.
- It remains to be seen if appropriate actions will follow this declaration.
- Under the law, EWS applicants may even find it harder to obtain positions. These problems can be addressed using the science of matching theory.
Unreserved to reserved
- Until now, India’s main reserve-eligible groups have been Scheduled Castes, Scheduled Tribes, and Other Backward Classes.
- In job and university assignments, there is a widespread tradition of first assigning a reserved category applicant to an unreserved position if he or she qualifies on the basis of merit alone.
- When unreserved positions are exhausted, a reserved category applicant may then be considered for a reserved position. A meritorious reserved candidate (MRC) is a reserved category applicant, who is tentatively assigned to an unreserved position.
- When the assignment involves multiple types of jobs or universities, the existence of MRCs raises two important questions. These are a below:
- Can an MRC move to a reserve position for a more preferred job or university place if he or she is tentatively holding a less preferred unreserved position?
- If such movement is allowed, what happens to the newly vacated seat?
- It is important to note that a 2004 Supreme Court decision in Anurag Patel v. U.P. Public Service Commission mandates that an MRC is entitled to move or “migrate” to the more preferred assignment.
- A 2010 Supreme Court decision in Union of India v. Ramesh Ram & Ors answers the second question for the case of public sector job assignments. It specifies that the newly vacated position is to be given to a candidate from the general category, who is not eligible for any reservation.
- That is, even if there is a more deserving reserved category applicant — say, another MRC who received a less preferred position — the newly available unreserved position can go to a potentially lower-scoring applicant from the general category.
- Therefore, it is important to note that one unintended consequence of this judgment is that the cut-off score for reserved category candidates can be higher than the cut-off score for the general category.
- At present, a small fraction of unreserved positions are tentatively assigned to reserved category applicants. This means that the number of meritorious reserved candidates is relatively modest compared to the number of unreserved positions.
- However, with the new EWS reservation amendment, a large fraction of general category applicants are expected to qualify as economically weak.
- This means that a large share of unreserved positions will be tentatively assigned to the EWS category. As a result, there will be many more meritorious reserved candidates. And the positions they vacate due to migration are to be offered to the general category candidates who do not qualify for EWS reservation due to the verdict as pronounced in the Ramesh Ram case.
- This may result in a reduction in the number of positions offered to those in the EWS category.
An example concerning the most sought-after government jobs:
- For example, under the system used by the Union Public Service Commission to allocate the most sought-after government jobs in India, such as in the Indian Administrative Service, a non-EWS applicant from the general category would take newly vacated positions following migration, increasing their overall share.
- In all likelihood, the cut-off scores will be higher for EWS candidates than for non-EWS general category applicants, meaning it’s harder for the poor to qualify than the rich.
- Creating such a large reserved category results in a big challenge to the implementation of Ramesh Ram, or any system based on the idea of a meritorious reserved candidate.
Horizontal or vertical?
- Another implementation challenge with the new amendment is that the new law does not explicitly state whether the new EWS reservation is horizontal or vertical.
- This is despite the clear distinction made in the landmark judgment in Indra Sawhney v. Union of India (1992).
- A horizontal reservation is a ‘minimum guarantee’, which only binds when there are not enough EWS applicants who receive a position on the basis of their merit score alone; if so, the bottom-ranked general category selections are knocked out by the top-ranked unselected EWS candidates.
- With a large number expected to qualify for EWS, the 10% minimum guarantee will already be achieved essentially in all applications. This means the policy, if applied horizontally, will virtually have no effect.
- A vertical reservation, on the other hand, is an ‘over and beyond’ reservation. This means that if an applicant obtains a position on the basis of his or her merit score without the benefit of the reservation, it does not reduce the number of reserved positions.
- This important distinction appears not to have been a part of discussions leading up to the passage of the law. A government memo suggests that the new EWS reservation might be vertical, but it is important that this issue be clarified.
- It is important to note that these issues can be resolved using a well-designed assignment mechanism and transparent rules about processing of reserves.
- Research done by some experts show how it is possible to adapt certain mechanisms for India and satisfactorily implement reservation policies, as they are envisioned in Indra Sawhney.
- Moreover, lack of clarity on implementation opens up possibilities to distort or even manipulate outcomes, undermining policy goals. It can confuse the public and keep university or job assignments in limbo for years as courts process legal challenges.
- India’s new EWS reservation policy is heading in this direction unless these implementation issues are addressed head-on.