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Oct-Dec2002-10(4)
CASE STUDY
Cross-subsidy in public
hospitals
Sreejit E M
It is interesting to note that ethics in medicine
has different connotations to different people. What some believe to be ethical,
others may call unethical. This is illustrated by the following examples drawn
from my own experiences as a trainee in general medicine in one of the teaching
hospitals in Pune. As a first-year resident trainee, the duties that one was
expected to perform included venepuncture (letting blood through skin puncture)
for laboratory investigations. As in most government hospitals, the facilities
were found wanting as far as provision of disposable syringes, needles, sterile
cotton swabs and gloves was concerned. The sheer number of admissions would
deplete government supplies.
After exhausting all methods of procuring these
materials through government sources, one had no choice but to ask patients to
get them from private pharmacies. A significant proportion of patients who
needed these services were too poor to buy them. In such situations we turned to
'richer' patients for these things. It was left to the resident doctor's
imagination to decide which of these patients and their relatives were 'rich'.
Many relied on the patient's occupation as a guide.
Some went by their conduct and demeanour. A few of the relatives who were
perceived as arrogant and uncouth were also made targets for this charitable
work.
The patients and their relatives were tricked into
believing that the purchases were for their own good. Little did they realise
that a surplus of these materials was bought to replenish the ever-emptying
stores in the hospital.
One of the other duties for a first-year intern was
to arrange CT scans for poor patients, which in those days were carried out at
private hospitals. This would involve negotiation with managers of these firms,
for a rebate on these scans, as most patients couldn't afford even a tiny
proportion of the scan fee charged. It was not uncommon to plead with the
managers to have scan fees waived in exchange for ampoules of the contrast dye
used in CT scans. These dyes would cost about Rs 200 in the market. Acquiring
these ampoules posed problems for the residents. The price of these injection
ampoules was as outrageous as the fees for CT scans. This ruled out the
possibility of getting them even from the richer patients, as was done to obtain
syringes, etc. The solution lay with a very special group of patients
frequenting the government hospital - those admitted with complaints of
insecticide poisoning. Suicide formed the cause for the intoxication in a large
number of these patients. As in most instances, they were registered as
medico-legal cases, which prevented them from going to a private hospital.
Stigma and fear of death would make these patients
and their relatives receptive to the demands of the doctors who would extract
their pound of flesh by way of a prescription including injection ampoules of
the contrast dye, and other paraphernalia required in the wards.
In some instances the relatives were told that
these ampoules of contrast dye were actually a miracle antidote for the poison.
This would send the relatives running to the nearby pharmacy to get the
medicines lest the delay should endanger the lives of their dear
ones.
As residents we were also told of an incident where
a particular doctor had stepped up the dose of Atropine to make the patient
delirious, thereby sending a veiled message (albeit untrue) that the poison had
affected the brain. The strategy was apparently meant for those who did not
comply with the doctor's orders. This behaviour was not approved of by most
residents. Interestingly these ampoules were very similar to the commonly used
multivitamin infusions (MVI) ampoules in size and shape. For inquisitive
relatives, an MVI ampoule would be broken and mixed with dextrose solution in
front of their eyes to reassure them that the 'expensive lifesaving injection'
was, indeed, being given. The contrast dye would then find its way to the store
of 'loot' gathered over a period of time. This would be used for the purpose of
striking deals with CT firms for scans for poor patients.
The onus of collecting these materials for patient
use was on the first-year trainee doctor (JR or the junior resident) who was
assigned the task of amassing syringes, gloves and other paraphernalia well in
advance to avoid a scramble on admission day. Each medical unit had its small
storehouse in the form of a cupboard. It was not an uncommon sight to see junior
residents of different units talking about their prized collections. Camaraderie
between JRs would also help the less fortunate borrow from those with a better
stock.
For the smooth functioning of the ward and prompt
and efficient management of the patient, it was deemed necessary for the unit to
keep a good reserve of these materials. More seriously ill patients would have
prolonged hospitals stays if one depended solely on government supplies which
were not only of an inferior quality but also available in inadequate
quantities. All this had the tacit support of seniors in the unit. Although the
practice was not endorsed by those in administrative or academic bodies, it was
never condemned, either. Perhaps endorsement would mean acknowledging the
constant shortage of supplies; this would expose administrative failings in
ensuring a steady stock. At the same time, the practice could not be discouraged
because then the normal day-to-day chores of the wards would come to a grinding
halt.
This account paves the way for some questions.
Where do we draw the line? Are we right in labelling a person rich or poor for
the purpose of extracting supplies for the hospital? After all, it is very
relative. We are also guilty of deceit. Can one small wrong be justified because
it is helping us prevent a bigger wrong arising out of a problem which is not
the doing of the doctors? Do these actions subvert established codes of ethical
conduct? Are the resident doctors not guilty of deceiving one set of patients
and relatives? Do they merit a reprieve because their actions were guided by the
sole intention of serving the poor? Resident doctors would argue that such Robin
Hood antics were needed to ensure that the system did not collapse. Surely, this
was the least pleasant way of addressing the issue of lack of basic amenities in
hospitals.
Let us not forget that such undignified methods
were resorted to only after more acceptable measures of addressing the problems
failed to elicit a response from the authorities. What happens if a poor patient
with a potentially curable head injury is left to be managed without a scan
because he is unable to afford the fees charged by the CT firm?
One also has to ponder the fall-out of this
practice. Some critics would argue that the silent approval of one's actions
paves the way for deceit of larger magnitude later in their careers. In an era
of falling ethical standards in public services could such practices lead to
more serious problems? Does the end always justify the means in such
circumstances?
Dr. Sreejit E.M.,303
Marvel, Shastrinagar housing society, Andheri (W), Mumbai. E-mail:emsree@yahoo.com
Commentary: living by
deceit
CC
Kartha
Thank heavens we did not have similar moral
dilemmas when we were residents.Much has changed since the time of my internship
nearly three decades ago. The private sector in health care has grown
disproportionately and has better health care facilities than public hospitals
have, specifically in terms of access to newer technologies. However, this
advantage is denied to most of our people because they have insufficient means
to meet the escalated treatment costs.
A caring, concerned and compassionate physician
today habitually confronts the setting in the case study presented here. In
finding a solution he is often in conflict with the dictates of his conscience.
The necessity of speedy action forces one to follow one's nose. At times of
relative leisure he ruminates over the ethics of his deeds and often takes
refuge in the maxim: "The end justifies the means."
The problems narrated in the case study are not
rare; they are unlikely to be resolved in the near future. The callous response
of administrators and the mute endorsement of deception and wrong-doing by
seniors in the profession reflect their inability to grapple with such
disturbing issues and find appropriate solutions. However, their lack of concern
cannot legitimise such unseemly acts by subordinates. Impropriety does not merit
a reprieve. Robin Hood antics may occasionally be condoned in exigent
circumstances, but they cannot be approved as a rule.
The essence of the vexatious instances cited in the
case study is scarcity of money in public-funded hospitals. How often, and how
seriously, have medical professionals deliberated to find means to prevail over
administrative apathy, and to discover novel ways of mobilising resources for
such institutions? There is no dearth of funds when meetings are to be arranged,
when financial support has to be found to attend conferences far and wide, and
for other private activities of doctors. Why do the beneficiaries not contribute
a small proportion of their extras to a permanent patient care fund in their own
hospitals? Suppliers to hospitals can also be approached to donate a small share
of their profit to the same fund every time they procure an order from the
institution. These voluntary grants are ethically more acceptable than robbing
rich patients through deceit or bartering in violation of the law. Honesty and
trustworthiness are vital in health care.
Lest one forget, "There is none so cruel as the
lying ascetic who lives by deceit. A weakling's philanthropy is a sword in a
eunuch's hand." (Tiruvalluvar: The Kural).
Dr. C.C. Kartha,Dean
Academic Affairs, Sree Chitra Tirunal Institute for Medical Sciences and
Technology, Thiruvananthapuram 695001,E-mail:cckartha@sctimst.ac.in