The unspoken background of the debate on the ethics of doctors advertising (1, 2, 3, 4)  is globalisation and how it affects the medical profession, whether it is their right to advertise, their obligation to provide information, their opportunity to earn foreign exchange, or their duty to provide care.

 

Any model of development which addresses the task of providing health care to all must presuppose a social commitment by medical professionals. Why build hospitals in rural and tribal areas if doctors are going to settle in the West, or pack themselves in metropolises? Unfortunately, most doctors are driven by the profit motive. They leave rural areas unattended, confining themselves to a few cities where their increased density draws them into unhealthy competition - hence the call for advertising.

 

At the heart of the problem are deep-rooted weaknesses in our culture and education system. We are made only technically proficient; our education does not instil in us an ethos by which we live our lives. Nor do we understand the philosophy and history of the subjects we learn in schools and colleges. 'Specialisation' means technical compartmentalisation of a subject in our minds. That is why the pursuit of science in our universities and national research and development institutions has failed to generate great contributors like Raman and Bose in the latter half of the last century. It seems that even medical education suffers from this problem. Teachers have failed as a community to inspire students; they have failed to convince, by setting an example, that competition amongst doctors by advertisement in any form is unethical.

 

It is true that word of mouth by a doctor is a form of low-key advertisement. However, when done among patients, their relatives and friends, it is a fair reflection of a patient's direct experience with the doctor. It is also a check to doctors' efforts at self-promotion.

 

The power of the electronic medium enables it to reach many more potential clients than can word of mouth. But without equally available information on doctors' failure rates, and their patients' evaluations, people looking for doctors through internet advertisements risk being misled by savvy doctors. Only if such an electronic check exists, and is provided alongside the ads could advertisement by doctors be considered fair and ethical. We cannot count on an alert media to protect patients from incompetent doctors.

 

Dr Malpani equates 'advertising' with 'providing information'. Information can be provided on the internet without advertisement. Doctors can use the electronic media to place a mega directory on a website. Software allowing people to locate a doctor would make information accessible without fancy advertisements to lure patients. This would take care of Dr Malpani's (3) objection that word of mouth does not favour younger doctors. The 'grey beards' who unfairly use their weight against freshers as contended by Mamdani and Mamdani (4) will lose their grip.

 

Those who support doctors' advertising quote Western codes which permit the practice (2,3). Jesani has pointed out that the call for advertising in the US stems from the insecurity of corporate-controlled health care with its own serious problems (4). Besides, should we equate the Indian and American situations just because globalisation has forced us into a free market economy? The American system offers some consumer protection; we are not able to do this.

 

Dr Malpani refers to 'the demands of changing times', to advocate advertisements by doctors. Our health care system is not effective beyond urban limits because doctors have ignored the demands of the times for several decades. Now, globalisation seems to apply a much needed balm to our pricked conscience.

 

I would like to cite the example of Baba Amte, a lawyer by profession. He attended a six-month course in tropical medicine and then established a home for leprosy patients at Warora, called Anandwan. Cured leprosy patients earn their living and run the village with a self-confidence that has to be seen to be believed. Baba Amte's sons and their wives have acquired medical degrees and devoted their lives to rural and tribal health care, at times against the government's serious antipathy towards the cause.

 

One son, Dr Prakash Amte, along with his wife Dr Mandakini, has worked since 1973 amongst the inaccessible Madia Gonds at Hemalkasa, promoted education and even produced two Madia doctors who have decided to go back to work for the tribals in the jungles instead of starting clinics in a city or abandoning the country. Dr Vikas, the elder of the two sons, looks after the growing activities of Anandwan and several other major projects. The next generation of Amtes has also committed itself to this development programme.

 

Unfortunately, Dr Vikas and his wife Dr Bharati are hard pressed to find permanent doctors to help run the hospital at Anandwan, though this beautiful village is close to the Warora railway station. Unlike the Amtes and their dedicated teams, scores of urban doctors don't seem to sense that 'the demands of the changing times' are to serve the rural and tribal populations. They seem to be eagerly looking forward to the patriotic feat of earning foreign exchange to eradicate the nation's poverty.

 

 

SK Bhattacharjee, Molecular Biology and agriculture division, Bhabha Atomic Research Centre Mumbai - 400 085.

 

The practice of medicine has undergone many changes over the years and will continue to undergo many more changes - in concepts and in practice - in future. It is, therefore, unrealistic and unfair to expect the medical profession to accept and adopt all of the ethical principles that were laid down years ago (1). Modifications must be made by the governing bodies and physicians must accept the changes.

 

I propose that - as is the practice in the United States - doctors in India should be allowed to advertise their services. Before I proceed further, let me make it clear that I would personally not advertise: either because I find it difficult to totally shake off old, established beliefs or because my own field (pathology) does not require advertising. However, I would defend the right of other physicians to advertise.

 

Dr Pandya argues that medical professionals have peer-reviewed journals to produce their research papers in and thus 'advertise' themselves to their peers. However, as he himself has pointed out some years ago (2), Indian doctors rarely publish. Moreover, Sahni et al (3) showed some years ago that only five per cent of Indian doctors read medical journals. This avenue of spreading information about oneself is thus blocked for most physicians.

 

The argument has been made that allowing advertising will permit doctors to make tall claims. The cure, then is to make our medical councils, advertising agencies, and the Advertising Standards Council of India more accountable. Preventing advertising because of the existence of misleading advertising is like banning cricket because of some matches are fixed. The solution is to prevent the fixing, not the game.

 

Finally, the change in medicine is exemplified by the fact that many hospitals, especially the private or corporate ones, have marketing departments. There have even been suggestions that the word 'patient' be replaced by 'client' or 'customer' (4).

 

But this much is clear: change is inevitable. In an age when patients are considered to be consumers and when doctors can be sued for poor services, surely it is incorrect not to allow doctors to advertise. The same rules have to apply to all the players of the game.

 

 

Sanjay A Pai,Consultant Pathologist, Manipal Hospital, Airport Road, Bangalore