Example 1: Litigation to Ensure Access to Morphine in India
Litigation: Public Litigation Case (No. 942/98) in the Delhi High Court (Dr. R.B. Ghooi).
This is an example of public interest litigation on behalf of cancer patients without access to morphine for palliative care. In 1998, a private citizen, Dr. Ravindra Ghooi, filed a lawsuit on behalf of cancer patients in India. He requested that the court provide rationalization of procedures for the supply of morphine for medical purposes.
In 1985, the Narcotic Drugs and Psychotropic Substances Act (NDPS) enacted strict controls on the manufacture and distribution of morphine in India. This had a tremendous impact on the use of morphine for medical purposes. Supplies of medical morphine plummeted from over 750 kilograms per year in 1985 to only 56 kilograms per year in 1996. Thus, while India was the major exporter of opium to the world, patients with severe pain did not have access to morphine. Moreover, a whole generation of doctors graduated without experience in using morphine for palliative care purposes and unaware of its potential for treating patients.
Dr. Ghooi filed a lawsuit after the death of his mother. His mother had breast cancer, but due to a previous history of diabetes and a stroke, she was not a candidate for aggressive cancer therapy. Nonetheless, she suffered from significant pain. Her physicians were not able to obtain even 1 mg of morphine for her treatment. Dr. Ghooi himself advocated on behalf of his mother, encountering bureaucratic barriers and expending time and money meeting with government officials, but was ultimately unsuccessful.
After exhausting his administrative remedies, Dr. Ravindra Ghooi filed a lawsuit in the Delhi High Court.
Arguments and Holding
In 1998, the High Court affirmed, “It is a right of patients to receive any medication they need, particularly morphine.” The Court then directed the state government to speedily attend to morphine requests and to pending hospital applications for morphine licenses. It further encouraged patients to approach the court if unsatisfied.
Commentary and Analysis
This court case worked in tandem with other advocacy efforts to increase access to palliative care medications. In 1999, the Pain and Palliative Care Society formed to develop community-based palliative care provision in India. Over the next seven years, the Society helped to establish twenty outreach palliative care programs throughout Kerala. By 2002, eight of the twenty-eight states in India amended their rules governing access to morphine.
Additionally, Indian physicians, WHO, and academic experts in the US joined together to reform the barriers to pain management. In 1994, Indian physicians formed the Indian Association of Palliative Care (IAPC)—disseminating knowledge of palliative care through regular conferences and a journal. IAPC, the WHO and academic experts in the US worked together with the national Government of India, their counterparts in a number of states, numerous physicians, and their respective pain and palliative organizations throughout India.
Nearly every government in the world is a signatory to three international drug control conventions: the Single Convention on Narcotic Drugs of 1961 (the primary treaty regulating opioid compounds and their precursors), the 1971 Convention on Psychotropic Substances (designed to control psychoactive drugs) and the 1988 Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances. These treaties aim to control the illicit use of non-medical uses of opioid drugs, but at the same time recognize the medicinal properties and scientific uses of pain medication. For instance, the Single Convention provides that: “the medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering and that adequate provision must be made to ensure the availability of narcotic drugs for such purposes.”
Many countries wrote their opioid control laws in a different era. At the time the laws were written, countries understood addiction to be characterized by withdrawal symptoms upon cessation of use. Since opioids always produced withdrawal symptoms upon cessation, lawmakers across the world believed that opioid use inevitably led to dependence. We now understand addiction as defined by compulsive behavior and continued use despite harm or drug-related problems, whether or not physical dependence is present. Therefore, the laws of many countries reflect an outdated understanding of addiction.