HANDBOOK ON MEDICAL ETHICS

The socio- political duties of the doctor

Upholding the 'dignity and honour of the profession’
The 'Code of medical ethics' (1) issued by the Medical Council of India states that physician is expected to uphold the dignity and honour of his profession. Furthermore, it states that'a physician should affiliate with medical societies and contribute his time, energy and means so that these societies may represent the ideals of the profession'.

It goes on to add, 'a physician should expose, without fear or favour, incompetent or corrupt, dishonest or unethical conduct on the part of the members of the profession'. Medical ethics has been defined as the analytic activity by which the concepts, assumptions, beliefs, attitudes, reasons and arguments underlying medico- moral decision making are examined critically(2). Hence let us analyse these guidelines in the current practical context and follow them to their logical, scientific conclusion.

Medicine - a profession?
Over the last two decades, and especially in the last few years, there has been a steady erosion in the dignity of the medical profession in our country. Simultaneously, there has been a marked increase in the number of doctors, especially with the mushrooming of private capitation- fee medical colleges in several parts of the country.

From an initially perceived service- oriented group, doctors are now being increasingly viewed as commercial agents. Previously, an overwhelming majority of fresh medical students would say, when asked, that they joined medicine in order to be able to do good to sick people. Although this may, at times, have been only lip service, it was anathema to openly say that one had joined medical school in order to become wealthy. But now it is not unusual to find students saying that they have entered the medical profession to earn money. 'Isn't this a politically appropriate attitude in a market economy?', some would argue.

It would be simplistic to berate only the medical profession for its fall from grace. A socio- political system in which health can bc bought makes access to good health care the prerogative of the rich and forbidden fruit for the poor. The medical profession has been used in this set- up as nuts and bolts to keep this ramshackle machinery going. The powers- that- be have seen to it that enough high- tech hospitals and well-trained medical personnel are available at their beck and call. As for the rest, a neglected public health system is 'a favour done to them'. The medical community has been a silent accomplice during the establishment of this warped model.

Health - a socio- politically determined issue
But, one may ask, where does the dignity and honour of the profession figure in all this? In fact, the health of the community is mainly a politically determined issue. A simple example will illustrate that the practice of medicine is being distorted in a ghastly manner by socio- political realities. Take for instance a child from a poor family who is brought to a general practitioner with gastro-enteritis. The general practitioner prescribes antibiotics, an antipyretic and an antispasmodic. The child develops severe dehydration the next day and is referred to a hospital. There he is treated with intravenous fluids and other supportive management and fortunately recovers from the illness. The child is discharged and the parents are asked to give the child hygienic food and boiled water. A few days later the child develops gastro-enteritis again.

Let us analyse the facts stepwise. Why did the child develop gastro-enteritis in the first place? Because he did not have access to clean drinking water. How is this the concern of the doctor? Many believe that it isn't. The doctor's duty, they say, is limited to passing the examination in preventive medicine during his undergraduate studies and advising the child to drink clean water.

The fact that we are supposed to treat the primary cause of disease and only secondarily give symptomatic and supportive treatment has been forgotten.

The doctor did prescribe antibiotics to take care of the causative germs, didn't he? The fact that gastro-enteritis is often caused by viruses which are not affected by antibiotics has been lost sight of. Careful clinical assessment and a simple stool test would have made this apparent. Moreover, an antispasmodic is often hazardous in this situation. The doctor probably knew this, so why did he prescribe it? It may have been that the stool test was too expensive for the parents of the child and they were keen to get the frequency of stools reduced by any means since both were daily wage earners and the child was left in a small hut with two other children.

Why, then, did they not 'go to the public hospital in the first place? The hospital was far away. Waiting in the out- patient queue would mean losing a day's wages. And anyway, several of the drugs prescribed in public hospitals have to be purchased from the chemist.

Why, then, did they agree to go the hospital the next day? Because now the child's condition was serious and he would be admitted immediately without having to wait in a queue.

Why did the child develop gastro-enteritis again? The parents could not ensure that the child remained clean while they were away at work. In fact, it was impossible to be clean for a moment, living in a hut on the bank of the sewer.

To carry forward the argument to its logical conclusion, a scientific approach to the problem would be to identify and tackle the root cause of the problem, which is not which infective organisms, but a socio-political set-up ensures unhygienic living conditions for the majority. The doctors in this instance are forced to carry out minor repairs on the terminal manifestation of widespread social injustice.

Getting to the root of the problem
It is a shame that the medical profession has been taken for (and has allowed itself to be taken for) granted. It speaks poorly for the dignity and honour of the profession that it shies away from the root of the problem.

In order to meaningfully improve the health of the community, and, incidentally, restore the honour of the medical profession, efforts to bring about a sea change in the socio-economic-political structure are necessary, rather than being passive tools trying to superficially patch a rotten system. In more practical terms, it means that doctors cannot simply say, 'Politics is a dirty game and I do not want anything to do with it', because to do this would be unethical.

Let us consider another case. Malappa, a sickly infant, is brought by his mother to a public teaching hospital. He is suffering from a condition known as protein-energy malnutrition. The infant is grossly underweight and in a poor general condition. He is examined by the doctors and found to have florid signs of protein, mineral and vitamin deficiencies. In fact, Malappa is a veritable text-book picture of protein-energy malnutrition. The doctors and medical students have elaborate discussions on the classification of his condition, the metabolism of calcium, iron, amino acids and fatty acids. Malappa is given a high protein diet along with supportive treatment. His mother has already run out of the few rupees she had left with her and her older daughter Ponamma, aged 3 years, is starving since 2 days. Fortunately Malappa recovers and goes home after a week. What was his illness due to? Simply, lack of food. And why did he not get food? Because his father, who was a construction worker, died a month ago due to a fall while constructing a parapet, and his mother's meagre earnings were not enough to provide enough food. Since construction work labourers are an unorganised sector living on daily wages, their families are usually not compensated in case of accidental death at work.

What will happen to Malappa now? In all probability, he will fall ill again due to lack of food.

Now isn't it clear what a peripheral, meaningless role is played by the medical profession? The ruling class does not want a starvation death to come to public notice. Not only would this expose the total absence of social security, it would also embarrass the politicians who would like us to believe that we are proudly marching into the 21st century. So the medical profession helps to salvage infants like Malappa till they become critically sick again. There seems to be no effort by the medical profession to address the issue at the fundamental level. Isn't it obvious that protein-energy malnutrition is an easily preventable condition? Is it not, then, logical to direct one's efforts towards equitable distribution of food? It is not as if India is short of food grain. In fact, we often hear of excess stocks rotting in government godowns. Whether we like it or not, the medical profession, if it has to provide holistic care, must do more than trying to merely seal the numerous leaks of a decayed machinery.

Without doing so it is meaningless talking of the dignity and honour of the profession.

Medical associations, societies and organisations
It is obvious that doctors should actively participate in the medical society of their speciality. This should help them to interact with others, keep abreast of scientific developments and carry out constructive programmes. Let us again consider a concrete example which illustrate the realpolitik of profession societies. The major cardiac scourge in India is rheumatic heart disease. This preventable illness has been eradicated in most developed countries. In India it continues to cripple and kill hundreds of thousands of young people, especially the poor, every year. One would expect that the cardiological fraternity in our country would include the eradication of rheumatic heart disease as one of its primary goals. On enquiry we find that there has been no major effort to tackle this difficult , unglamorous problem. Successive, increasingly lavish, annual conferences of the Cardiology Society of India are held and hundreds of papers are presented. The latest, most expensive, high-technology, inappropriate palliative treatments for coronary artery disease are discussed in great detail. Why do we see this lopsided approach? It is easy to argue that the eradication of rheumatic fever entails better hygiene and better nutrition which are the concern of politicians and bureaucrats and not doctors. In that case, what are we talking about when the code of ethics says that doctors must contribute their energies so that these societies may represent the ideals of the profession?

The above example can find analogies in most of the other professional medical societies. Many of these organisations have spawned a breed of 'chronic medical politicians' who remain office- bearers over years. Far from being interested in science, their main aim is to gain publicity, power and wealth. With such fossils at the helm, it is not surprising that the few genuinely scientific papers in medical conferences are submerged in a flotsam of repetition (' re- search') and lies. One usually returns from a conference having learned untruths. Another task neglected by these organisations of specialists is the laying down of guidelines for diagnosis and treatment which would help maintain scientific standards. Such guidelines for practice should predispose physicians to change their behaviour. It is true that guidelines are unlikely to effect rapid changes in actual practice in the present environment. (3,4)

We need effective role models for implementation of the guidelines. Erring doctors should be sharply reprimanded and penalised by their professional bodies. But here, in India, we lack the very first step - the laying down of guidelines. Once again we realise that if we are to implement ethical principles meaningfully, we need to participate in a political struggle to change the agenda of medical societies as they exist at present.

Exposure of unethical conduct
This is the most contentious issue. On the one hand it is unethical to speak badly about one's colleagues. On the other hand the Code of Medical Ethics advises the exposure of unethical conduct by other members of the profession. It is well known that unethical conduct is widespread, and most doctors would have come across at least one instance. Let us enumerate three examples of dishonest, corrupt or unethical practices that have come to public notice over the last few months: cut- practice, the kidney transplant racket, amniocentesis for female foeticide.

One may argue that unless one has proof, one should keep quiet. Everyone knows how difficult it is to have concrete proof, especially since doctors are not trained to -- and should not attempt to -- be super- sleuths. The Code (1) provides the solution to this dilemma. Even 'if doubt should arise as to the legality of the physician's conduct, the situation under investigation may be placed before officers of the law.'

If even a few doctors follow this recommendation sincerely, it would open up a Pandora's box of grime and without such a public display of what is wrong in the medical profession there can be no corrective steps.

Given the present system, one wonders whether those who laid down these guidelines in the Code of Ethics and keep them updated check whether any of them are practiced. How many doctors risk ostracisation whilst exposing truant colleagues? Most of us prefer to cover our eyes with blinkers fooling ourselves.

References

1. Medical Council of India:Code of Medical Ethics. New Delhi: Medical Council of India.
2. Gillon R: Medical ethics: four principles plus attention to scope. British Medical Journal1994; 309: 184- 188.
3. Lomas J, Anderson GM, Domnick- Pierre et al: Do practice guidelines guide practice?New England Journal of Medicine1989; 321: 1306- 1311.
4. Epstein AM: The outcomes movement- will it get us where we want to go?New England Journal of Medicine1990; 323: 266- 269.

The professional man in essence is one who provides service. But the service he renders is something more than that of the labourer. It is a service that wells up from the entire complex of his personality. True, some specialised and highly developed techniques may be included, but their mode of expression is given its deepest meaning by the personality of the practitioner. In a very real sense his professional service cannot be separate from his personal being. He has no good to sell, no land to till; his only asset is himself. It turns out that there is no right price for service, for what is a share of a man worth? If he does not contain the quality of integrity, he is worthless. If he does, he is priceless. The value is either nothing, or it is infinite.

So do not try to set a price on yourselves. Do not. measure out your professional service on an apothecary's scale and say, “Only this for so much.” Do not debase yourselves by equating your souls to what they will bring in the market. Do not be a miser, hoarding your talents and abilities and knowledge, either among yourselves or in your dealings with ;your clients, patients or flock. Rather be reckless and spendthrift, pouring out your talent to all whom it can be of service. Do not keep a watchful eye lest you slip and give away a little bit of what you might have sold. Do not censor your thoughts to gain a wider audience. Like love, talent is useful only in its expenditure, and it is never exhausted. Certain it is that man must eat, so set what price you must on ;your service. But never confuse the performance, which is great, with the compension, be it money, power or fame, which is trivial.

Judge Elbert P. Tuttle 1957 (Courtesy: Mr. Nani A. Palkhivala)