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Medical Ethics in
India: A Frank Discussion Between Doctors |
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The medical profession in India is in crisis and
society no longer holds the medical profession in
the high esteem it used to in the past. Most honest
doctors would agree that ethical standards in the
profession are deteriorating, and this seems to
be a downward spiral. When, where and why does the
rot start – and what can we do about it ?
Dr Malpani spoke to Dr Pandya, who recently retired
as Head of the Dept of Neurosurgery at KEM Hospital,
Bombay, and who has tried to improve ethical standards
in India.
Dr Malpani: Let’s
start at the beginning. Most people still believe
that when youngsters join medical college in order
to become doctors, they usually do it because they
have idealistic goals and want to serve and help
others. Of course, it doesn’t hurt that doctors
have a good income, but that’s like icing
on the cake . You would expect that by the time
they become doctors, after going through five &
half years of medical college and three years of
residency , they will have imbibed these ideals
and goals from their seniors so that they can serve
society as doctors. However, in real life, the situation
seems to be completely the opposite, and idealistic
students seem to become hardened and cynical by
the time they graduate. Is it something that we
do to them in their years of training ?
Dr Pandya: Well , most of the time when we try to
analyse this situation , we have learnt - rather
painfully and rather sorrowfully - that we’ve
already lost the battle before they even join medical
college . By the time they are in the eighth standard,
they seem to have only one priority in life - to
get as close to 100% marks as possible, by any means,
fair or foul. This is why school classes seem to
have been replaced by coaching classes .
This means that by the time this child has finished
his XIIth Std and is about to join medical college,
a mind set has already been established.
Most students are fiercely competitive – and
seem to feel that the end justifies the means.
In medical college , things get worse - the eventual
goal , of course , is to get as close to the top
as possible in the final MBBS exams because all
subsequent registrations and post graduate seats
depend on that .
I don’t think medical students are really
looking at medicine as a profession which is meant
to serve humanity – that has now become incidental.
The second major problem which has set in is the
advent of the private medical colleges . Here, you
end up paying through your nose for that seat. So,
you have already made a big capital investment –
and the family than expects a return on that investment
! The other factor which worsens the situation in
medical colleges is a rapidly reducing numbers of
role models , because the kind of teachers that
they encounter in medical colleges today are no
longer the kind of teachers we encountered when
we were students.
I think what is also happening is the numbers of
youngsters who everywhere earn huge incomes very
fast – everyone wants to become rich quick
! Medical college students are no exceptions - they
also want what their friends have - a flat, a car,
posh consulting rooms. All these factors combine
together, so that the chief goal of a medical student
now is to become successful in practise, rather
than provide good care to patients.
Dr Malpani: A lot of doctors
feel that society owes them money because they work
so hard. They complain that they work so much harder
than other people – who are not as well qualified
and yet are earning much more . This is why they
feel that deserve to earn more. What do you think
about that?
Dr Pandya: Well this is not new – doctors
have always worked hard, and medical students have
always worked hard in order to become doctors. I
don’t think it was any different in my time.
It is expected that medical students will need to
work harder than say, students in arts or commerce.
I think what has changed is their perception - in
what they intend to do and what their ultimate goal
is. In olden days , students needed to have a have
a vocational aptitude before they considered going
in for medicine. Today, of course, this is not considered
at all. Not by the parent, certainly not the child
herself or himself because the child is relatively
immature, not the teacher in school, and certainly
not the people who select who is going to enter
the medical college. In the past, factors like whether
you were interested in human beings and how you
behaved with others was an important criterion in
selecting medical students. It still is, in medical
colleges in UK and USA today, where students are
interviewed before the final selection. With our
system, we select any Tom , Dick and Harry whose
only criterion is that he has obtained more than
99 marks.
Dr Malpani: Doctors feel
that all of society has become corrupt today, and
it’s not fair to judge them by different standards
– the same benchmarks should apply to all
professions. If we are willing to accept corrupt
politicians, then why should we single out corrupt
doctors
Dr Pandya: This is a specious argument. Doctors
have chosen to become doctors because they have
chosen to deal with life and death, suffering, sickness
and pain . I think doctors, after being so highly
educated – and claiming to be more cultured
than the average Johnny, cannot use this as a justification.
Surely your education must teach you what is right
and what is wrong - and even if the rest of the
world does what is wrong we should choose to ignore
that and concentrate on what is right and do it.
Dr Malpani: A lot of junior
doctors justify their unethical practises by saying
– my seniors are doing it as well –
why shouldn’t I ?
Dr Pandya: The same rule applies – even if
my parents do something wrong it does not justify
my doing the same wrong. You have to use your own
conscience as a guide.
Dr Malpani: Isn’t
it true that this kind of advise might be easy to
preach , but hard to practise ? Perhaps it’s
possible to follow in government hospitals where
you get a guaranteed salary , and you can speak
the truth fearlessly - I am not going to do this
because I do not think it is right - never mind
every one else. But when you are in private practice
, and if you take this sort of ethical attitude
( This patient does not need an operation and therefore
I am not going to do it) , what’s going to
happen is that doctors will stop sending patients
to you. You are going to have to worry, because
just as you have responsibilities to your patients,
you also have responsibilities to your family –
after all, you have to make two ends meet !.
Dr Pandya: We have umpteen examples in the medical
profession today of individuals who have done well
for themselves and have risen to the top without
being unethical. Names which come to mind include:
Dr Noshir Wadia, Dr Dastur , Dr Udwadia, and Dr
Chaubal. None of these people have stooped to any
kind of malpractise, they are absolutely straight
– and they are at the top of the profession
. They are doing reasonably well – and have
an unmatched reputation to boot. Of course, if you
set your aspirations at an unrealistic level –
if you want the latest model Mercedes , a bungalow,
and a holiday abroad every 3 months, then you will
have to indulge in underhand practises. However,
if you have rational goals - I want shelter, food,
education for my children and care for my family
, these can be acquired by any individual who is
honest and straight forward.
Dr Malpani: Many doctors
would say that in the past there was not much competition
- there were very few doctors , or many of these
people you have described were born with silver
spoons, which is why they have done so well. However,
for every example of a "good" role model
you give, they can offer the example of five "
bad " role models – doctors who are known
to be corrupt and unethical, and yet who are at
the top of their profession.
Dr Pandya : I think everybody has to make a personal
choice in this situation - you have to choose which
role model to follow.
Dr Malpani: I guess part
of the problem is that there is no deterrent to
being corrupt. If there was a downside or risk associated
with being corrupt, then people would be much more
careful – and think twice about doing something
wrong. Here , it does not matter if you are corrupt
- the guy on the top is the most corrupt and gets
away with it - that is the sort of lesson you are
teaching juniors.
Dr Pandya : That is true. To a point I think deterrents
do have a role to play , but fundamentally everything
depends on the individual’s character. Deterrents
are a good way for society to impose disciple or
ethics on the individual , but I don’t think
it’s an ideal method for promoting ethics.
The ideal method for promoting ethics is to cultivate
character and this is something which is extremely
difficult and time consuming – not something
which can be done overnight . It is an unfortunate
fact that the agencies which we have which are meant
to enforce ethical standards, which are meant to
serve as disciplinary bodies , are the most corrupt
themselves. So we are deprived of this method of
enforcing discipline. The Medical Councils have
proven themselves to be worse than useless , and
they have been shown over time also to be extremely
corrupt.
Dr Malpani: When you want someone to do something
, it is a simple rule in human nature that either
you use a carrot or a stick, so that if society
wants doctors to be ethical, non corrupt doctors
should be honoured; and doctors guilty of unethical
practises should be punished. Unfortunately, that
does not seem to be happening.
Dr Pandya: I don’t think that this is true.
I think society gradually - not instantly- does
recognize doctors who are good and ethical. I agree
it does take a long time to build up a good and
honourable reputation but then this lasts for a
lifetime ! And the best thing is you also get a
good night’s sleep !
Dr Malpani: But I don’t think corrupt doctors
lose any sleep thinking of themselves as being corrupt.
Everyone justifies what they do . Most doctors will
justify their giving a kickback by saying that if
they don’t give it, they will not have any
patients at all to see – and they need to
survive. The other justification is if I don’t
do this surgery ( whether or not the patient needs
it ) some other doctor will do it – so that
rather than let someone else does it, why don’t
I go ahead and do it myself. They have their logical
justifications , and since most doctors are intelligent,
they can rationalise what they are doing and salve
their conscience.
Dr Pandya: Of course, what’s interesting is
that when such doctors themselves , or their relatives
, fall ill they don’t go to equally corrupt
doctors ! In that case they then seek out the person
whom they know is ethical and honest and will give
them an unbiased opinion which cannot be challenged.
So I find it is strange that it is possible for
them to rationalise their acts – but, of course
you can also rationalize murder. I think this just
means that they do acknowledge that they have double
standards !
Dr Malpani: In a way this shows that these unethical
doctors are intelligent people, who can look after
their own interests. So, when they fall sick they
go to a non-corrupt doctor; but when they treat
their own patients, they feel that it’s not
in their own best interests to be straight.
Dr Pandya: It also means that they can differentiate
between what is right and wrong and they have willfully
chosen not to tread the straight and narrow path.
I have learnt now , rather painfully , that it is
probably unwise of any individual , including myself
, to judge another individual. All that I can say
is that as far as I can see it , this is the way
things should be done. Why somebody else should
follow another path is for them to decide. But I
still feel that any rational thinking honest person
should be able to differentiate between right and
wrong – and if he chooses to follow a wrong
path , that’s his business.
Dr Malpani: When most doctors start practice , they
don’t start it with the intention of being
crooked. However, when they hang out their shingle,
they find that the reality is that patients will
not come to them unless they grease the palm of
the local GPs. That’s what everyone else is
doing, so you better do it as well – the competition
is intense ! And when they start, they do it for
financial reasons . Most justify this by saying,
I need to do it now to survive - but after four
or five years, when I am well settled, I’ll
stop. The sad reality, of course is, that once you
start, you cannot stop – it’s a downward
slippery
slide ! What advise would you give a doctor who
is just starting practise ?
Dr Pandya: It is not an easy situation , and there
are two or three methods by which juniors could
be helped to stay straight. The first would be for
his senior to down load work to him. I know this
doesn’t happen often anymore, but it used
to happen frequently when I was a medical student
. Very senior consultants would act as mentors to
their post graduate students and say - come , set
up your clinic in this locality. I get lots of patient
coming from your area and I will direct them to
you. Dr Sanzgiri, Dr R N Cooper, Dr Joshi are some
famous names who come to mind, and many of their
students are now leading doctors. The second method
would be to encourage junior doctors to start practise
in the right town. Unfortunately, every one wants
to settle down in Bombay, Nagpur, Hyderabad, Bangalore,
Delhi – and this is neither sensible or practical.
If the same individual was to relocate in a relatively
small place , he would not encounter these teething
problems. The interesting thing is that in no time
at all, they have a roaring practise, with their
own bungalows and cars – because there is
no competition – and they are the only act
in town ! More importantly, they also have immense
social prestige, and they often leave their contemporaries
in larger towns far behind. The final method is
perhaps be the best – we need to develop some
means of identifying honest and upright doctors
who are competent and skilled, and then publicise
these names, so that they are available to all patients.
Dr Malpani: How does society do that? How does society
identify the crooked doctor? It’s practically
impossible for patients to do this !
Dr Pandya: The intelligentsia – the movers
and shakers of society - eventually make decisions
for the rest of society . If they decided, they
could set up a mechanism by which doctors could
be evaluated . I think there are enough honest and
decent doctors in any city, who will be willing
to participate in this kind of an exercise. They
would sit down very transparently, very openly and
evaluate other doctors . You could then publish
this list of reputed and ethical doctors –
and this list would help patients to identify honest
doctors of proven competence. You may not be able
to evaluate the crookedness of a doctor, but identifying
honest doctors will be a first step in the right
direction ! The list need not be comprehensive in
the beginning, but once it becomes an established
practise, doctors will start clamouring to be evaluated,
so that they can get on to the list ! Retired senior
doctors who have an unblemished reputation could
offer this service. I know this is not likely to
be a very popular suggestion, because doctors are
usually egoistic individuals who do not like being
judged by others – but if we do not establish
a mechanism of doing so, the good doctors will start
getting tarred with the same brush, and all doctors
will suffer as a consequence. Of course, the key
question is, who will bell the cat ?
Dr Malpani: Interestingly , this exercise has been
started in USA, and is called outcomes research.
The results ( outcomes) of surgery performed by
cardiovascular surgeons in New York are published,
and are freely accessible, so that patients can
look up this list, and then go to the doctor they
feel has the best rate of success. This can help
to weed out incompetent doctors, and set standards
of performance for the rest.
Dr Pandya: I agree that it may be hard to accomplish
this in India – but we cannot afford to give
up ! We need to persevere in our efforts, even though
we many not succeed. Changes for the better will
only occur if we start now, which is why we started
the Forum for Medical Ethics Society in 1995. The
journal we publish, Issues in Medical Ethics ( Foundation
for Humanisation, PO Box 26922, Santacruz (W), Bombay
400 054,
website: www.healthlibrary.com)
, is now doing very well, and is widely read and
appreciated all over the country. We are trying
to change things for the better , so that at least
we have peace of mind that we gave it our best shot
!
Dr Malpani: Isn’t it true that many doctors
are telling their children not
to take up medicine ?
Dr Pandya: Yes , and this is a shame ! Many doctors
feel the profession is going from bad to worse,
and they no longer share a sense of pride in being
a doctor. A wise doctor can pass on a lot of wisdom
to his children, and this is now sadly being lost.
I guess future generations will pay the price for
this, as the standard of doctors continues to decline
further, if we do not do something actively to arrest
this.
Dr Malpani: Isn’t it true that while most
doctors are aware of unethical practises and corruption
in the medical profession, they prefer keeping quiet
about this ? Society generally perceives that doctors
engage in a conspiracy of silence and secrecy –
and most doctors refuse to stick their necks out
by identifying "bad" doctors.
Dr Pandya: Yes, this is true. This is a major reason
why patients have not been able to lodge complaints
against doctors in the Consumer Courts. The Consumer
Court requires two doctors to verify that the case
has merit, before accepting a complaint against
a doctor. In reality, since doctors refuse to opine
against another doctor, most of these complaints
never see the light of day. While most doctors are
worried about the skeletons in their own cupboards,
if any doctor wants to improve the system, he needs
to have the guts to stick his neck out. He may get
ostracized by his colleagues in the process, but
there is really no other option if we need to set
our own house in order. Unfortunately, most doctors
are completely apathetic and couldn’t care
less. I guess this is indicative of the malaise
affecting the whole society at large. I guess this
is why we get what we deserve , including our politicians.
Dr Malpani: Why do we blame only the doctors ? Isn’t
it true that the entire medical system is morally
bankrupt ? What about the large corporate hospitals
– don’t these indulge in malpractise
as well by pressuring their staff doctors to admit
a minimum number of patients, as well as to generate
a certain amount of revenue ?
Dr Pandya: It is a sad reality that these hospitals
are profit-making bodies, and their primary concern
is going to be their bottom-line. However, they
cannot function without doctors on their staff,
and doctors could get together to resist these pressure
tactics. Unfortunately, doctors are often so embroiled
in petty politics, that they cannot band together
to look after their own interests.
Dr Malpani: What about the pharmaceutical industry
? Isn’t it true that they aggressively push
their products, and entice doctors to prescribe
the latest and most expensive "me-too"
pill – irrespective of whether or not it is
in the patient’s best interests ? Isn’t
this true of the medical equipment industry as well,
which wants doctors to buy the latest and newest
scanner. This means that doctors then get pressurised
into scanning large numbers of patients daily, whether
or not they need these scans, in order to make their
investment cost-effective.
Dr Pandya: Let’s not forget that these companies
are commercial organisations – and their goal
is to maximise their profits , by any means. If
doctors are willing to be bribed, it just shows
how morally bankrupt they are. In fact, a major
responsibility of a good doctor is to act as a gatekeeper
of medical resources, so that he uses them wisely
and efficiently for his patients. Unfortunately,
this misuse of medical resources is a worldwide
phenomenon – as documented by the many Medicaid
scams in USA. The Indian system is even sicker than
others – and the real tragedy is that the
sufferers are the poor defenceless masses, who cannot
fight back. There is no effective avenue for redressal
for the average aggrieved Indian patient today,
given the sad shape our judicial system is in.
Dr Malpani: Isn’t it true that many patients
have got fed up with the arrogant attitude of doctors,
which is why they are increasingly turning to alternative
medicine ?
Dr Pandya: Yes – this is a backlash we are
seeing, and an increasing number of people are trying
to find non-medical solutions to their problem,
because they are so unhappy with the present medical
system.
Dr Malpani: What advise would you give a patient,
so that he can protect himself from an unethical
doctor ?
Dr Pandya :.I would say just one thing – educate
yourself, so you have realistic expectations as
to what your doctor can do for you. Information
is power, and well-informed patients are in a sound
position to judge whether or not what their doctor
is telling them makes sense . The library you have
started, HELP, Health Education Library for People
at Kemps Corner in Bombay ( website: www.healthlibrary.com)
is an excellent step in this direction. Unethical
doctors are much more likely to promise the moon
– while honest doctors will present the facts
fairly and truthfully. Having a good family physician
who can guide you to a reliable doctor is very helpful;
as is getting a second opinion .
Dr Malpani: What are your final words ?
Dr Pandya: I’d say, go and see the movie,
Patch Adams. This is an excellent film, which shows
so well that there is a better way of practising
medicine. It reminds us that doctors are human beings
first and last – and that the best doctor
is one who follows his heart and takes an active
interest in helping other human beings !
This interview appeared
in Housecalls, published by Dr Reddy's Labs, India.
We would welcome your feedback!
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