Sunday, October 25, 2015

Ethics and the Medical Profession in the Indian Context

The following is a response that I wrote on my high school Whatsapp group in response to some heated debate about the Medical Profession and stories about their sub-standard ethics.  Blogging it for others.
All professions providing some form of service have a lot of regulations around ‘ethicality’ and ‘morality’. This applies to financial professionals – people who give investment advice to their clients as well as the medical profession. I have worked in the finance profession all my life and have now moved into a regulator role. And I am applying some of the principles that we adopt for the financial advisory profession in this discussion.
No one will grudge a super-specialty doctor charging high fees because he has spent years and money in acquiring his skill and he does deliver results! They have spent lakhs and crores on that costly private medical education or on equipment and therefore they must now recover their cost. It is called ‘Return on Investment’. Yes I get that! But this argument immediately throws the ‘Hippocratic Oath’ out of the window and brings the doctor down from the heights of being in a ‘noble profession’ to being just another businessman.
One of the tests of ethicality is ‘Conflict of Interest’.  In any doctor-patient relationship, whose side is the doctor on? Is the doctor looking out for the best interest of the patient or is he/she acting in self-interest?  This I where all the talk of the ‘cut’ business comes into play. If as a financial advisor, I get a cut for every mutual fund I recommend and get the customer to invest in, then there are no marks for guessing that my interest would be to recommend the mutual fund which gives me the highest commission rather than the one that is best for the customer.  I have immediately compromised the financial health of the customer. Translate this to the medical profession and you have a large number of stories of over-prescribing, over-testing, and even advising surgery when not warranted. There is both anecdotal evidence of this as well as established case law.  Just do a google search.
How often do doctors sit with a patient and their relatives and go through the case, discuss the pros and cons of various optional routes of treatment and explain the doctor’s reasoning for the line of treatment that is being recommended? If the medical profession is prepared to be called just another business then business ethics demands that they be transparent.  
In my google search I came across a book authored by Pune-based Dr Abhay Shukla and Dr Arun Gadre. It is an English translation of the Marathi one — Kaifiyat pramanik doctoranchi (reflections by sincere doctors). It contains interviews of 78 practicing doctors from Mumbai, Pune, Delhi, Kolkata, Bangalore and Chennai. “These whistleblower doctors have mustered the ethical courage to expose facts for the first time on such a scale,” Dr Arun Gadre says. Several doctors spoke up including Dr Vijay Ajgaonkar, senior diabetologist from Mumbai, who says, “Now our greed has increased to the extent that when a patient of one consultant goes to another consultant, the second one prescribes the same medicine, but merely changes the brand to show that he is doing something different. And it is true that this profession has now become completely commercial.” The book describes every unethical practice from the horse’s mouth: cuts or referral fees for diagnostics as well as medical procedures; ‘Study tours’, also known as foreign trips funded by big labs and pharma companies for doctors; hospitals employing people who will rush to an accident scene and act as social workers to get the injured to the hospital that employs them. Etc. Etc.
There is one bold argument that is commonly made- that C is for choice. Whenever I hear this I am reminded of the time when my late father died way back in 1994. My brothers and I were doing the rituals of the kriya karma and were in a grieving state . The ‘priest’ (who smelled money as my brother was working in the UK and I came from Japan) would recommend to us one ritual after another emphasizing how not doing it would bring some pain or harm to our dad’s soul. He would always end his dire warnings with the words “it is your choice” Similarly, when relatives are worried about the health of their loved one, the doctor is in a position of trust. And at that time if he/she is going to be conflicted and concerned about making a commission then how different is he/she from this unethical priest?  
Long story short, the medical profession surely needs some soul searching as to where it all went south.

And finally there are some good apples and some bad apples in every basket.  The problem is that the bad apples give the whole basket a bad name.