Daily Times

General (retired) Musharraf, former lord and master of Pakistan, finally appeared in a court trying him for serious crimes. What comes of it remains to be seen and, of course, I cannot comment on ‘legal’ matters since they are presently ‘sub judice’. Indeed, I love the Latin phrases that our legal fraternity throws around like ‘suo motu’, ‘sub judice’ and ‘res ipsa loquitur’ but then, as far as the trial of Musharraf is concerned, the legal term ‘res ipsa loquitur’ (the thing itself speaks or speaks for itself) is quite adequate.

Here I must admit that I have never read Latin but, as a medical student reading anatomy, I had to wrestle with Latin names of muscles, bones and organs. And then, during my surgical training, and then while taking multiple surgical board exams, anatomy was always around. I have a favourite muscle whose name as legend goes was once used when a ‘fellow’ of the Royal College of Surgeons (FRCS) was asked to say ‘grace’ in Latin before a formal dinner. The rather irreligious ‘fellow’, not being well versed in Latinate liturgy, stood up, repeated ‘levator labii superiorus alaeque nasii’ three times most sonorously and then said ‘amen’, and sat down. The aforementioned muscle besides being the muscle with the longest name in human anatomy also allows us to ‘snarl’, an action evidently frequently happening during the aforementioned trial.

My purpose is not to expound on the ‘righteousness’ of what Musharraf is going through or the legal basis of his trial. What I want to discuss is the simple question of whether Musharraf can be forced to undergo procedures for diagnosis or treatment of his ‘medical’ problems without going out of Pakistan. Obviously, my perspective is that of a surgeon but I share this perspective with most physicians who perform ‘invasive’ procedures, including heart catheterisation or placement of cardiac ‘stents’.

When the issue of Musharraf and his ‘heart’ disease was first raised, a slew of doctors with ‘impeccable’ credentials were trotted out in the media to insist that facilities in Pakistan were more than adequate to take care of the problems he was supposed to be suffering from. I entirely agree with that assessment. If Musharraf needs a heart procedure, there are many extremely competent physicians in Pakistan who can perform these procedures as well as any physician in the US or elsewhere. However, that is not the issue.

For those with short memories, I would like to remind them that, once upon a time, the real ‘lord of righteousness’ ruled Pakistan. He ordained that all thieves should have a hand cut off since that was the ‘Islamic’ punishment for theft but it never happened because no physician in Pakistan was willing to perform such a ‘surgical’ procedure on an unwilling ‘patient’.

There are essentially three situations where a physician can perform procedures on a patient without that patient’s permission. First is on a legal ‘minor’ but even their permission must be obtained from the parent or a legal guardian. The second situation is of an unconscious patient involved in a major accident or after being wounded in a skirmish of some sort. If an urgent life saving procedure has to be performed, physicians will go ahead without waiting for a formal ‘consent’ from the patient or the family.

The third possibility is when a patient is ‘non compos mentis’ (more Latin!) or not mentally competent enogh to make a proper decision. In such cases, physicians will then approach the ‘next of kin’ or, if no near relatives are available, a court of law for consent to perform that procedure. However, even when it comes to a court, the advice of the physicians taking care of that patient is the determining factor.

As a physician I can say with reasonable assurance that no physician in Pakistan is going to perform any ‘invasive’ procedure on Musharraf without his consent, unless of course the court rules that Musharraf is not mentally competent enough to give ‘informed consent’. It is extremely unlikely that Musharraf will be declared mentally incompetent. Sadly, neither stupidity nor hubris is accepted as proof of mental incompetence.

The intersection between medicine and law is always complicated. The law is concerned with guilt, innocence and punishment while medicine is concerned with a person’s well being. For a physician, the fact that somebody is accused or even convicted of heinous crimes is immaterial when it comes to taking care of that person as a patient. While working in a ‘county’ hospital during my surgical training in the US, I took care of many convicts from nearby jails. The important lesson I learned was that they had to be treated like any other patient.

Frankly, I cannot foresee a situation where a court can actually force a physician to perform any procedure on an unwilling patient especially if that procedure entails any serious risk. It is unlikely that any physician will agree to perform any procedure on an unwilling patient as high profile as a former president of the country. So, it seems to me that there are only two possible alternatives available. The first possibility is that the court ignores Musharraf’s claims that he is suffering from serious heart disease and decides that he is well enough to stand trial. This could create problems if Musharraf is really sick and develops life threatening medical problems during a prolonged and stressful trial. Here, I must admit that based upon media reports of Musharraf’s illness and results issued by the Armed Forces Institute of Cardiology, it does seem to me as a cardiac physician that there is some real medical basis for what happened. The second possibility is that the court allows Musharraf to proceed abroad for diagnosis and treatment. That, of course, carries the definite risk that once Musharraf leaves Pakistan, he will not come back to stand trial.

So, as they say in the old country, choose your poison.

The writer has practised and taught medicine in the US. He can be reached at smhmbbs70@yahoo.com