Indian Journal of Medical Ethics

Medical professionals today have been caught on the back foot. Patients no longer have blind faith in their doctors, and there are too many umpires watching. There is fear and mistrust on both sides. Paradoxically, all this also spells hope and opportunity for the discerning vaid. This hope is shared by many within the profession who wish to enter into a dialogue with patients, who do not have a compulsive desire to battle with them. These doctors prefer to walk alongside the sick and those in pain, rather than be isolated by society or monitored by external institutions.

The issues discussed here emerged at several workshops conducted by my colleagues and me in Mumbai. These were conducted in hospitals, on the request of hospital deans and with general practitioners and consultants in collaboration with medical associations.

In the workshops that we conducted for medical practitioners, we find that many doctors find democratic communication with face-to-face contact fulfilling. This interaction is more productive than one which depends on blind faith and obedience from patients. The fact is that doctors can and must do away with the notion that they are unchallengeable authorities, and the pressures that go with such a perception. They can shed the responsibilities associated with being all-powerful healers.

Making this shift can initially provoke anxiety. It can also be a learning experience, providing immense work satisfaction and making the doctor hungry for more. 'I am no longer tense when patients ask me difficult questions,' said one doctor. 'At least I know where I stand and I feel good that they are confident enough to express their concerns. It took me some time to accept that I may not have all the answers but it turned out for the best.' A family doctor said his practice had actually picked up after he started asking his patients: 'Do you have any questions that you have hesitated to ask because you fear that you may offend me? Please do ask them.'

Listening to a patient enables a true exchange, one that is transparent and non-threatening. Listening as an active process is possible when the listener's body language reflects an attitude of genuineness. The fact is that such an attitude is mandatory not only for the patient's good health but also for the doctor's emotional well-being. I believe that the doctor attempting to heal the sick also gets healed. A healed professional is also more effective than one who is traumatised by self-mutilation.

Doctors who receive money surreptitiously and hold many hospital attachments without paying proper attention to any of them, are harming themselves. The mind records all these activities with their associated energy-positive and negative. When negative energy dominates, it damages, though the conscious self is unaware of this. It affects everyone around, including one's loved ones. Being ethical actually ensures good health and helps one evolve as a professional.

Many doctors pride themselves on being up-to-date with modern advances. They boast of being highly skilled in using gadgets or understanding the mysteries of the human body. That makes them good technicians but not necessarily good doctors. Patients can end up with many hi-tech reports. They are submitted to these tests through smooth talk and at exorbitant costs. A 'cut' reaches the referral physician. The patient is cheated and the doctor is unknowingly traumatised as a result of suppressing the awareness that 'I am doing what is not required and it is actually wrong.' This accumulated emotional harm diminishes the impact of the doctor's work. The joy and meaning in life are lost. It is seldom understood that a doctor is one who relies on conscience as much as on skill.

At the start of a workshop for interns, one doctor candidly stated that his only interest was to make money. As the day progressed he stated that money is a by-product of hard work and skill. By the end of the workshop he said that he would not earn money at the cost of his conscience. Nowhere in medical training do doctors learn to process their feelings and find their own balance and comfort zones to be integrated as human beings.

In the journey of the medical professional, spiritual upgradation is as important as upgradation of skills. Lifestyle issues must be tackled by mental health holidays, dialogues with colleagues, reasonable harmony with oneself and others, and brutal honesty during failures. This builds an emotional energy bank-a prerequisite for ethical practice. A chaotic lifestyle creates the perfect conditions for an abusive medical practice.

In many of our workshops we ask doctors to discuss any near-death experiences, or the death of their loved ones. However, they have learned to block emotion and it takes some time for them to start expressing their feelings. A gynaecologist said he believed that he could have done better to save the life of his father but failed. Many felt guilty and felt that they had not done enough. One doctor burst into tears and blamed me for asking such a question. It was felt that in the medical profession crying is a sign of weakness.

Some doctors feel uncomfortable discussing the death of their patients with their relatives. This often reflects an inability to process pain, distress and death as emotional processes in one's own life and understand this in the lives of the relatives. This distorts communication and the ethical base of functioning. Those who process pain and accept it as an inevitable part of life function better and are able to relate to those in difficult circumstances. This leads to harmony in situations where exchanges are not always pleasant and comfortable between the patient and doctor.

At one of the workshops a successful family physician said that being ethical had lost him money and even friends for his colleagues teased him for being upright. Later, he said that at least he was content with what he had and could hold his head up in society without shame. Still, his convictions were coloured by intermittent doubt.

Many doctors who have resisted the temptations of a 'cut' and a market-driven economy, today feel that they were foolish and naīve in not making extra bucks. Such professionals find themselves lonely and isolated amidst turbulence as new values find their place in an era of liberalisation. They must seek the company of colleagues with similar perspectives. This horizontal bonding, and sharing, will give them a sense of belonging and reinforce their conviction that they have acted correctly. Doubts will always exist, and they will often get resolved just by the process of expressing them. Some indicators that doubts are not useful are when one takes the criticism of colleagues very seriously, starts brooding about one's own behaviour and values success in financial terms.

As patients' awareness and understanding increase, health professionals should respond not with a defensive and protective armour but with a relaxed approach. They should replace fear and paranoia with love and compassion. This is because healing begins from within oneself. The road of ethical practice is not a journey of dos and don'ts, right and wrong. It is one in which the patient and doctor walk hand in hand.