A doctor's murder

The murder of Dr Vasant Jaykar (1), a well-known cardiologist practising in private hospitals in Mumbai, created panic among the city's medical practitioners. This was understandable because Dr Jaykar's murder was 'commissioned' by the aggrieved brother of a patient who died while under the doctor's treatment (2).

The reactions of individual doctors and their organisations (2) have had certain common themes: the practice of medicine has become a dangerous occupation; patients have unreasonable expectations; they should understand that medicine is imperfect and incomplete.

Such reactions were expressed by professional organisations when the Consumer Protection Act was made applicable to the medical profession, in 1993. They are repeated after every publicised doctor-patient dispute. However, there has been no rational analysis of the situation by medical professionals; knee-jerk reactions dominate.

The failure of self regulation

The practice of medicine has always been guided by self regulation, whose use differentiates a profession from commerce. Profit is a secondary motive in a profession, while it is the primary motive in commerce. Statutory bodies performing this self-regulatory function therefore play a crucial role in maintaining the profession's integrity.

The Medical Council of India (MCI) and its state chapters were constituted to maintain ethical standards and to enable self regulation in the medical profession. However, over the last few decades, these statutory bodies have become dens of corruption and opportunism for medical politicians. As medical education became commercialised, the alliance between corrupt medical council members and politician owners of capitation fee-based private medical colleges destroyed the profession's ethical fabric.

With this downslide in self-regulation came the transformation of the doctor-patient relationship, based on trust, into a comercial transaction. Dialogue between doctor and patient, central to any successful therapy, became rare. Compassion, competence and confidence, the profession's three pillars, were replaced by a single pillar: Cash.

Technology gone wild

Other elements over the last two decades have contributed to this change. The advent of medical technologies providing better treatment outcomes for various diseases has hastened the commercialisation of medicine. Technology is beneficial if used by a trained and qualified person and for the proper indications. In India, it is used more as a commercial venture than as an investigative or therapeutic tool, marketed as panacea for every pathology, without infrastructural backup, optimum monitoring or training. Patients are rarely informed of the costs and of alternative, non-technological modes of treatment.

These aggressive marketing methods have increased society's expectations, creating a belief in the average patient's mind that everything can be cured or controlled. As a result, both society and the medical profession forget that medicine is not always an exact science.

These trends have also increased the cost of health care. The commercial concept of 'value for money' has taken root in the health services. When the patient's increasing expectations are not fulfilled in spite of spending huge amounts for technological treatments, the doctor-patient relationship which is already under strain breaks down, leading to disputes. In a violence-prone environment, such disputes can take a violent turn. Dr Jaykar's murder is not the only instance of a physical assault on a doctor.

The need for communication skills

The doctor-patient relationship is based on trust, nurtured by communication and ethical medical practice. The increasing use of technology, commercialisation, and declining ethical standards in the profession have made this communication difficult if not impossible. Consumer health organisations in India have found that the majority of medico-legal complaints result from communication failure. However, communication skills do not find a place in our medical curriculum, and only one medical college includes medical ethics in its curriculum (3).

At the same time, society sees no evidence that the profession takes action on complaints. The MCI's president's investigation has not stopped him from being installed as national president of the Indian Medical Association (4). Such actions send negative signals to the patient community about the medical profession.

It does not help the profession's cause that it has taken little initiative to improve the abymsal quality of our health care infrastructure.

Finally, it is necessary to emphasise that in society, doctors practising ethically get little support. "Costly treatment is good treatment," is a dangerous equation which seems to have taken root in society. This is manifested in the demands for expensive medicines and treatment.

Dr Jayakar's murder must be condemned. However, it is symptomatic of the many problems in our ailing healthcare services. Without a rational analysis of these problems, by the medical profession and by society at large, the present chaos will only degenerate into anarchy.

References:
1. Express News Service: Cardiologist shot dead in Khar. Indian Express, Mumbai, January 12, 2001.
2. Express News Service: Doctors upset by trend of violence. Indian Express, Mumbai, January 17, 2001.
3. Ravindran GD et al. Teaching medical ethics: a model. Natl Med J India 1997; 10: 288-89.
4. Sharma D. Medical body chief under cloud of suspicion in India. Lancet 2000; 356: 573-6

Dr Arun Bal,6 Mallika, Makranth Housing Society, SVS Marg, Mahim, Mumbai 400 016
Email:arunbal@medicalethicsindia.org.