Chapter 32: Medical ethics –how to do what is right
|"Reading about ethics is about as likely to improve one’s behavior as reading about sports is to make one into an athlete. "
- Mason Cooley.
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 ?
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 thoroughly imbibed these ideals and goals from their seniors so that they can serve society as caring and selfless 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.
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 This is why school classes seem to have been replaced by coaching classes .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 .Medical students are no longer really looking at medicine as a profession which is meant to serve humanity – that has now become incidental.
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 himself because the child is relatively immature, not the teacher in school, and certainly not the people who select who is going to enter 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.
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 most medical college professors today are "full-timers” who treat teaching as just a job they are paid to do. What is also happening is that there are now a large number of youngsters who 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.
Many patients today feel that medicine has become a business, and that doctors are just out to make money, by indulging in unethical practices such as unnecessary surgery; ordering expensive lab tests; and asking for excessive consultations amongst one another. They sense that doctors have become corrupt, and that unethical practices flourish. Doctors justify this by saying 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 ? A lot of junior doctors also justify their unethical practises by saying – my seniors are doing it as well – why shouldn’t I ? Many doctors feel that they are overworked and underpaid; and that society owes them money because they work so hard, so patients should not grudge them their fees.
Just like there are lots of corrupt doctors, fortunately there are also 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, and are excellent role models we can try to emulate. 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 doctor who is honest and straight forward .
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. 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. In the past, 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, 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 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. Retired senior doctors who have an unblemished reputation could offer this service. 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 ! 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, good doctors will start getting tarred with the same brush, and all doctors will suffer as a consequence,
While most doctors are aware of unethical practises and corruption in the medical profession, most 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. 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, and this is
indicative of the malaise affecting our whole society at large. This is why we get what we deserve , including our politicians.
Unfortunately, the entire medical system has become morally bankrupt . Large corporate hospitals too indulge in malpractise by pressuring their staff doctors to admit a minimum number of patients, as well as to generate a certain amount of revenue. 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.
The pharmaceutical industry is also guilty of shoddy ethical behavior. 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 . This is true of the medical equipment industry as well, which wants doctors to buy the latest and newest ( and most expensive) scanner. This means that doctors then get pressurised into scanning large numbers of patients daily, whether or not their patients need these scans, in order to make their investment cost-effective. 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.
Being ethical in your daily medical practice is straightforward if you remember the three basic principles of medical ethics: autonomy; beneficence; and non-maleficence. Being ethical simply means respecting your patient’s ability to make his own decisions for themselves; making sure that what you do helps your patients; and does not harm them. Finally, it all boils down to the golden rule – treat your patients the way you would like to be treated yourself !
Our education teaches us 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. You have to use your own conscience as a guide. Remember that we are all 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 . Society gradually does recognize doctors who are good and ethical. 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 !