1 July is observed as Doctor's Day in India to honour the legendary physician and the second Chief Minister of West Bengal, Dr Bidhan Chandra Roy. He was born on 1 July, 1882 and died on the same date in 1962, aged 80 years. Dr Roy was honoured with the country’s highest civilian award, Bharat Ratna on 4 February, 1961.
This is a significant day for doctors as it provides them with an opportunity to reflect on their career and remind themselves about practicing the art and science of Medicine and Surgery in an ethical manner. India is unique in the sense that patients revere their doctors. Majority of doctors in our country are sincere, honest and ethical. However, due to unethical practices by a small percentage of doctors (numbers increasing exponentially), faith in the medical profession, which was once considered to be the noblest of all, has indeed taken a beating. It is precisely this loss of faith that has resulted in patients ‘shopping around’ from one doctor to another in the hope of finding an honest sincere and ethical doctor. Sadly, in this endeavour, there is a possibility that patients might very well end up with the wrong choice, substantiating the view that finding the right doctor in India is a lottery!
Unethical practice has unfortunately penetrated every segment of medical profession. The aim of this article is to explore the Facts and Realities behind deteriorating Medical Ethics and suggest possible solutions to address some of the burning issues.
Why should ethics only apply to doctors when there is deterioration of ethics in just about every walk of life?
The patient trusts and places his life in the hands of the doctor. On many occasions, the patient discloses confidential information to the doctor which he might or might not have discussed with his/her spouse or family member. In no other profession does the individual place so much trust and faith. In some regions, particularly in rural India, the doctor is equated with ‘god’. The doctor is therefore duty bound to have a higher level of moral code of conduct compared to the rest of the population and must understand that he/she is in a very privileged position
Fact and Realities
Kickbacks - Nexus between doctors
It has become common practice to give ‘kickbacks’ to other doctor colleagues in order to get patients. As a result of this ‘unholy nexus’, patients are referred based on monetary reward from the receiving physician and not based on his/her competence. This sort of referrals (quite common) sets the ball rolling for a series of unnecessary investigations and treatment that patients experience without their knowledge.
Kickbacks — Nexus between doctors and Hospitals/diagnostic Centres and unnecessary investigations
There are doctors who receive regular kick backs for investigations ordered with diagnostic centres. Therefore, it is not surprising that unnecessary investigations, some of which are expensive, are ordered without any established indications. The harm to patient with this sort of philosophy is twofold – Firstly they are paying huge amounts for tests that may not be required. Secondly, they run the risk of being harmed with excess radiation if investigations such as CT scans (radiation dose equivalent to 500 X-rays) and PET CT (Radiation dose equivalent to 1000 X- rays) are performed repeatedly at frequent intervals without any evidence based indications.
Marketing Teams for Doctors
Practice of the art and science of medicine has come to such a passé that some doctors have marketing personnel on monthly pay rolls. Their job is to get more patients to the doctor by hook or crook.
Media adverts– Buying Space in Newspapers, Television/Radio Channels
World over, it is ethical to give an opinion or to present views relating on any medical issue when invited to appear on Newspaper/TV/ Radio to create awareness about disease, early detection and aspects relating to treatment. But to deliberately buy prime time space in newspapers, television and radio channels is highly unethical. Also, since this space is bought, one has the freedom to write whatever they wish. There are unfortunately no cross checks to see whether or not the matter is in the interest of readership nor whether it is ethical. The readership, many of whom are unaware whether the write up is purchased or invited contribution believe what is written, which may not be true.
Doctors nexus with Pharma Industry
Many doctors are given regular monthly kickbacks by pharmaceutical industry for prescribing their products. When a Pharmaceutical company insists on being honest and does not give kickbacks, there are doctors who threaten the Company representatives by not prescribing their drugs. Hence the Pharmaceutical industry has given up. Some doctors receive kickbacks from Pharmaceutical industry for every dose of chemotherapy that they prescribe for cancer patients. For the same reason, many surgeons/surgical oncologists and Radiation Oncologists administer chemotherapy.
It may be pertinent to mention here that it is well recognized fact world over that chemotherapy must be administered by medical oncologists and not by surgeons/radiation oncologists.
Doctors and Unethical trials
Greed, lack of regulation, lack of accountability, lack of firm laws and a lenient society is allowing unethical trials to flourish in India. Research methodology and ethics relating to Research is not part of medical curriculum in India. Hence, many doctors in India who have very little knowledge about research and very few publications in peer reviewed journals undertake Research in Private Hospitals. The huge pool of innocent patients and unethical principles are a lethal combination in India. Even the educated are not very much aware of the drugs being prescribed. They have full and implicit faith in the doctor and rarely do they question as to why they are prescribed the drug. ‘Informed consent’ is something that is taken very lightly in India. Scores of patients are recruited into trials without being consented properly.
It is a well recognised fact that less than 25 percent of drugs introduced in the past decade have been breakthrough drugs. Seventy-five percent of the new drugs have had only a marginal benefit/no benefit. Only trials conducted in the Randomized Controlled trials (RCT) setting have a proven value in determining whether or not the drug in question is effective (the best form of evidence). However, very few trials in India are done in the randomized setting
Unnecessary procedures – both diagnostic and surgeries
Many doctors perform surgeries without any established indications. For instance, when someone presents with metastatic cancer, there is hardly any role for surgery as it will not prolong life.
In many instances their survival is measured in months when they present with metastatic disease. Such patients require compassionate counseling and palliative care and not aggressive surgery. But there are Surgeons who operate on patients with well-established multi organ metastatic disease regardless of any considerations. This not only involves enormous expenditure but more importantly, compromises any further quality of life that the patient may have left – not only is this practice unethical, it is in fact inhuman.
- Ethics now has an established place within the medical curriculum throughout the Western World. It is sad that medical Ethics is not part of the curriculum in medical schools in India. There is an urgent need for Ethics to become part and parcel of the Medical Curriculum in India.
- The Medical Council of India (MCI) Act has laws in place to firmly deal with doctors who have deviated from the code of ethics. The Govt. of India must ensure that these laws be strictly enforced by the powers that be.
- The concept of ‘Family Physician’ is more or less extinct in India. The Govt. of India and Powers that be must revive the concept of ‘Family physician’. We, as a country, must switch from doctrine of practicing the more aggressive “Americanized Medicine” to “British Medicine”, which is far more conservative and evidence-based, which would go a long way in reducing unethical practices.
Doctors must, from time to time, reflect upon their careers and must endeavor to practice the art and science of Medicine and Surgery in an ethical manner. It is imperative for both patients and doctors to work together at re-establishing some of the lost trust, and truly, there could be no better day than doctors’ Day to reinforce the unique relationship between the doctor and patient. On the Occasion of doctor's Day, I would like to remind myself of an important component of Hippocratic oath – and that is to ‘keep the good of the patient as my highest priority’.
I could not think of a more apt prayer on this occasion than what was penned down by Sir Robert Hutchison, a legendary Physician in 1953 that was published in the British Medical Journal. What he said some 75 years ago in an environment of medical practice quite different from what we are accustomed to, remains still relevant today.
From inability to leave well alone;
From too much zeal for what is new and contempt for what is old;
From putting knowledge before wisdom, science before art,
cleverness before common sense;
From treating patients as cases; and
From making the cure of a disease more grievous than its endurance,
Good Lord, deliver us