CORRUPTION IN HEALTHCARE AND MEDICINE
Bioethics and corruption: a personal struggle
The author attempts to give a general picture of corruption, especially in the area of healthcare. Corruption ranges from fraud, through deceit, bribery and dehumanisation, to immeasurable moral decay.
As a bioethicist who has challenged corruption in various ways, the author approaches this worldwide plague mainly on the basis of his personal experience. He does not offer a recipe for successfully combating corruption, but tries to provide some ways and means to fight immorality without self-defeat. Bioethics is not a discipline whose task is to investigate, expose, or punish corrupt people. A number of agencies exist for this “noble” job. Nevertheless, an ethics teacher should not be completely indifferent to obvious and harmful immoral behaviour, regardless of his/her personal compulsions. It is not the “patient rights” that threaten the prestige of the medical profession; it is rather the bad apples that infiltrate the moral mission of this esteemed work.
It seems that the hardest challenges in the struggle against corruption are bad laws-laws that provide loopholes and immunity to immoral dealings. In a stable, strong democracy, morally unfounded laws can, and will be changed. Where real democracy exists, they would not even have come into effect.
Facing corruption: a personal account
“Where are all the bioethicists when you need them?” asks the title of an interesting article by Subrata Chattopadhyay and his colleagues (1) . They refer to the fight against corruption in healthcare. Well, here I am, one of the few. I finished the study of law and then worked at a medical university where quite accidentally, I became a teacher of Marxist ethics, then medical ethics, and finally bioethics. At that time, in the 1980s, no one in Hungary knew what bioethics was. I consider bioethics simply as a discipline of ethics in healthcare and medicine. Robert Baker, a prominent bioethicist from New York, answers the question: “What is bioethics? in this way:
I take bioethics to be a multidisciplinary field whose members include administrators, clinicians and health professionals of all sorts, historians, lawyers, literary scholars, nurses, philosophers, physicians, policy analysts and policy makers, psychologists, religion scholars, scientists, social scientists, theologians and others united by the common purpose of analyzing, consulting, researching, studying and attempting to address, mediate and offer ethical solutions or resolutions to actual or potential ethical problems arising in biomedicine, biomedical science and healthcare (2).
Way back in the pioneering times in Hungary, in the early 1980s, medical ethics was the exclusive domain of medical doctors. Their main topics were: Hippocrates, the doctor as the ship’s captain, and the so-called “tips” (parasolvencia, bribes, under-the-counter payments, etc.) given to doctors secretly for various favours.
Due to the birth of bioethics and its subsequent advances, I too felt the need to deal with issues connected with patient rights; and instead of a one-sided approach, I initiated professional and public debates on genuine ethical questions such as, death and dying, euthanasia, human experimentation, confidentiality, and the like. At the same time, I strongly felt the need to challenge immoral behaviour within the healthcare system. This “atypical heroism” might have come from my own feelings of intolerance towards the prevailing widespread corruption and immorality, and my deep sympathy for the “underdog”. A famous Hungarian writer and poet said something like this: “Guilty (is he) who is silent among corrupt and unjust people” (Mihaly Babits, 1883-1941). I just did not want to be a silent bystander, especially when my job was to improve the moral/ ethical standards of future doctors and nurses.
It is obvious to me that corruption and immorality can hardly be separated. The Oxford English Dictionary defines corruption as “(a) moral deterioration, especially widespread; (b) use of corrupt practices, especially bribery or fraud; (c) an irregular alteration of a phenomenon from its original state; (c) decomposition, e.g. a corpse.”
Is it possible that corruption is inbuilt in human nature? Is there any sign in the earliest life of a human being of greed or the hunger for power? Does a newborn already have the potential to become corrupt one day? Yes, I believe it has. It probably depends on how the possible contributing factors, such as socialisation, the cultural environment, education, family life, the stability of the community and the country influence and/ or determine the individual’s life.
If someone can kick the kindergarten teacher at the age of five without retribution, just because he/she comes from a rich or influential family, if the same person can get high grades in elementary school and high school for the same reason; if he/she is admitted to university and receives a diploma in exchange for expensive “gifts” or valuable favours to certain teachers instead of hard work; then the seeds of corruption are well-rooted in this human soul.
Transparency International is the “watchdog” but it is hard to imagine that this kind of dishonesty would be included in its corruption scale. Bioethicists cannot and should not take over the job of the law enforcement agencies, the state administration, or the other dozens of agencies whose duty it is to guarantee the lawful functioning of the healthcare system. Unfortunately, what is lawful is not necessarily moral.
Bioethicists ought to fight for good laws which do not discriminate, and do not force the healthcare profession to resort to corruption in order to solve the problems of their daily existence. However, the bioethicist’s opinion is hardly sought by the lawmakers.
Over the years I have really had to struggle, face serious conflicts, guard my job and face vicious attacks from several directions.
The enemy of the medical profession
In some circles I was considered an enemy of the medical profession. While I kept writing and speaking about timely issues of bioethics, I developed a close awareness of the everyday realities of healthcare, since I was teaching English to many physicians. Besides the issues of euthanasia, abortion, informed consent and many others, my attention extended to corruption in my own country and worldwide. Under- thecounter payments to doctors were not the only negative phenomena that had to be faced.
Yes, the practice of tipping, giving money in envelopes (in this part of the world not a red but a white one) to doctors and nurses for various favours is generally an act of corruption. It is especially so, if money or free services are openly demanded, or forced out through manipulation. Besides tipping, I have had to deal with such subjects as malpractice, manipulation of waiting lists, therapeutic nihilism, scientific fraud, sexual abuse, brutal and shocking information to patients, irrational and unjust allocation of resources, kickbacks, and unprincipled solidarity with doctors committing immoral acts, and so on. More than just a few persons, patients and relatives, and even students came to me for help, believing that through my writings or public appearances I could do something to solve, or at least alleviate their problems concerning healthcare. Sometimes I could help; most of the time I could not.
I noticed that the WHO definition of health, i.e. “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”(3) was a wonderful goal for health for all. However, a legitimate question may arise, namely – how many people in a state of social well-being can we find in countries where corruption is widespread and the level of poverty staggering?
We organised an international meeting in my home town under the name of the East-West Bioethics Conference. Here, I must mention that without moral and financial support coming from the West (e.g. Nuffield and Soros Foundation, the Hastings Center) in the form of invitations, scholarships and libraries, the former communist Central and East-European countries would still be in the stone age as far as bioethics is concerned. My work and “unusual” interest put me in the leadership of the International Network on Petty Corruption in Health Care, as one of the projects of the International Association of Bioethics. The Network became a forum for a worldwide discussion on corruption. Of course, even this prestigious organisation had neither the authority nor the means to investigate any practice of corruption that speakers around the world brought out into the open. They could, however, release the pent-up steam that had accumulated in them over a period of time.
No one could follow the aftermath, though it seems hardly possible that those openly voiced immoral practices continued to be ignored in all the respective countries. The participants in the Network came closer to each other, shared their experiences in some detail, and also tried to find ways to combat corruption. The sponsors did not seem to mind that corruption was on the agenda in every international congress. The media was eager to cover some of the stories heard during the session.
At home, my involvement in exposing corruption was not welcomed, to put it mildly. Although a university lecturer usually works until the age of 70, and a “cooperative” person, can work as an emeritus professor practically until death; I was kicked out of the university at the age of 65.
What could I have done to keep my job? The recipe- perhaps in many places in the world-is manifold. First of all, stay away from criticising medical professionals, and avoid conflict, especially with the establishment. It is also good to remain silent, or talk about irrelevant things. Once during an institutional meeting, the boss who kicked me out read the newest fire regulation page by page, so that no time remained to discuss pressing problems concerning the future plans of the Institute. That reminds me of Professor Donald Evans from New Zealand, who often remarked sarcastically how safe it is for an ethicist to speak and write about nonsense such as whether angels have beards or not. So, with a little exaggeration, I would say that a bioethicist who challenges corruption is embarking on a suicidal venture.
On the other hand, the teaching of bioethics could do something to ease the tension generated by corruption. As I have already mentioned, teachers are needed who are at least totally moral and committed to their patients, justice and honesty. Those who are teachers should themselves set good examples. Even if a teacher is not a Mother Teresa or a Nelson Mandela, he/she should be a person who wants to imprint in the minds of future professionals the ancient truth that medicine is a moral enterprise.
I feel that my own human dignity is much more important to me than to follow any formula for success. Unfortunately, corruption exists in all areas of life. Some forms are well hidden, others are irritatingly open. I could easily put together a long list of various types of corruption but I just mention two that have recently deeply affected the moral sense of millions of Hungarians.
The smoker and the paedophile
The government has launched an all-out campaign against smokers. They must not smoke in restaurants, in the entire area of hospitals, near to playgrounds, bus stops, coffee stands, and so on. The fines are high, but the results are not so spectacular. At the same time, Parliamentary representatives have nine designated places in the building where they can ease their nicotine hunger. Strangely, anti-smoking tablets are sold like hot cakes, and those who have no jobs, inadequate income and no hope feel that the last resort to enjoying something in this life is becoming more and more only a dream. No doubt smoking is a health hazard, but prevention ought to be emphasised and invested in, instead of declaring smokers as public enemies. In contrast, while smokers are hunted down, paedophiles can feel safe because no one really goes after them, especially if powerful persons are behind them. Should I just close my eyes to this and do nothing? Or should I expect bus drivers or locksmiths to fight for the rights of people, whether they are smokers or patients? Of course, not all bioethicists can, or even should be, frontline fighters against corruption and injustice.
The other example has only as much to do with bioethics as smoking, but serves as a good example of the serious moral harm that a person in high position can cause to a whole society. Recently, the president of the Hungarian state was accused of plagiarism concerning his doctoral dissertation. The accusation was well founded, and the president had to resign. His party tried to defend him till the last, and called those journalists who exposed him “pen-pushing terrorists”. It is very sad because the moral decay of the highest institutions shakes the citizens’ feelings of right and wrong and thus the moral texture of society weakens.
In the communist era, there was much less corruption and it was much less harmful. The reason was probably the policy of full employment. Everybody had to have a job. Now, in our developing capitalist system there are a growing number of jobless people, and unlimited ways to steal, cheat, embezzle and get rich by being corrupt. Of course, poverty is not the reason for corruption, but it may be a warm bed for it. I say openly that socialism saw less corruption than our present capitalist system. For one thing, socialism operated in a police state. There was a watchdog at every corner. Corruption could occur mainly in the top party hierarchy. The majority of the people lived-although in a very modest way-in financial security. Those who wanted to loaf around, ended up in jail. Now millions of Hungarians live below the poverty line. The visible contrast between the rich and the poor is irritating. Some people believe, quite justly, that not every rich person has piled up his wealth in a legitimate way. Thus, some may think that the best way to combat immorality is to be immoral as well.
As I have mentioned elsewhere: corruption destroys human relationships, creates an atmosphere of the law of the jungle, promotes subservience, pessimism and anxiety, leads to moral chaos and makes the functioning of the society almost impossible. Where corruption becomes a way of life, flexibility and adaptation to that kind of social environment come to be much more valuable than hard work, talent, diligence or achievement. Undoubtedly corruption in healthcare has serious implications for the fate of patients [Emphasis added] (4)
One other problem with criticising corruption is that as soon as it is done, the defenders of corruption, and/or the protectors of professional prestige, accuse the critics of generalisation. Every writer and speaker knows that generalisation is absolutely unjust and unfounded. Thus, it is obvious that there are, indeed, dedicated doctors, nurses, and researchers who keep the system running.
The selection or contra-selection of bioethics teachers
As I mentioned, I became an ethics teacher quite by accident. The leader of my institute who happened to be the ethics teacher died, and somebody had to take over. I was that somebody with a law diploma and two years of education in philosophy. Since then, practically anybody can become a bioethics teacher. In fact, ethics, or bioethics can be integrated into the curriculum, and it can just as easily be eliminated from it. In most of our universities and colleges, anyone who has good personal connections with the leadership, and stays as far from controversial issues as possible, is a suitable bioethicist. You may last longer as a bioethics teacher if you emphasise the superior moral virtues of the medical profession during lectures and/or seminars, and give good grades at the exams. No one controls the quality and the effectiveness of bioethics teaching. There is no unified teaching programme. There are neither defined goals nor reliable ideas about the changes of moral status of medicine and healthcare. The feedback of the students is important but hardly a decisive value judgment.
The opinion of Kamran Abbasi that “Corruption is an important but overlooked medical issue” (5) is somewhat questionable. In my opinion, it is not overlooked but a very risky business, for many reasons. One of them is obvious-it is hard to prove. It is even harder to find whistleblowers who would provide proof of corrupt practices. Very few people would risk their very existence. For example, it is not a coincidence that one of the main ethical problems in many countries is the failure to report incompetent or impaired colleagues. Those who embark on opposing corruption cannot even rely on social research carried out by various surveys. I know of some of these, and I feel that many of them are absolutely unreliable. They are quite distorted because very few people would admit openly that, for example, they have bribed doctors. There is no proof whether they did or did not. These surveys usually show that the money received by doctors illegally is rather negligible and it is thus not worth dealing with. I believe, however, that even one’s spouse does not know how much one receives through forbidden channels. Instead of studying apologetic surveys, one should look into the healthcare system of such countries as Costa Rica. From various sources, I have heard that there is hardly any significant degree of corruption in this Latin American country.
In order to face corruption in healthcare you should be in close touch with reality. You cannot be sitting in an ivory tower, and rely on hearsay. Only a very few bioethicists have the opportunity to follow closely what is going on inside an institution. Somehow you must have firsthand experience or reliable eyewitnesses; otherwise you are entering a minefield.
Dealing with corruption is further complicated by the fact that some form of corruption is legalised. For instance, our widespread tipping system, although illegal, is taxed! There are, indeed, some doctors and others who do report a meagre income at the end of the year. The newest twist in the law that has just recently come into effect is that a doctor can accept tips only if his or her boss previously permits it! I need not remind anybody that the biggest money makers, or padded envelope collectors, are exactly those who might permit the subordinates to augment their income through the “gratitude” of their patients.
Another example is that in our state-run healthcare system, hospitals may increase their income by creating elite wards for those who wish to receive superior service, and are able to pay for it. It can only be done by violating equality. Yet another example might be the composition and working of the research ethics committees. They are established everywhere just as the laws demand, so that lay people can feel assured knowing that there is an organisation that is supposed to guard their interest, and thus they cannot be victims of foul human experiments. The major problem is, however, that many of these research ethics committees are made up of exactly those persons who have some personal interest in drug companies. If they have no truck with drug companies, then they are usually selected on the basis of their ability to nod their heads.
There may be another reason for “overlooking” corruption, namely, the division of labour among bioethicists. There are those who deal with theoretical questions, as for example, what autonomy means, or when life begins; and there are those who study and write about something that is fashionable, attractive and/or believed to have important practical value. Fortunately, no one can be forced to cope with corruption.
What can bioethics do?
In general, bioethics has already done a lot. Just to mention one instance, it has achieved a worldwide implementation of patient’s rights.
While I agree with Kamran Abbasi that the interpretation of ethical issues is culturally bound, I cannot accept the claim that “One doctor’s corruption is another doctor’s cultural norm”. I would rather agree with Subrata Chattopadhyay when he says that culture should not be used as justification for corruption (private communication). I should add that enlightened, wellinformed individuals may not stick to their cultural tradition if their own autonomous decision brings them a better life. If we look around the world, we see, for example, that such ethical principles as informed consent broke through many cultural barriers and became a way of life in the physician-patient relationship.
Nevertheless, bioethicists can combat corruption-if they have both courage and interest-by working to enact better laws, to widen public control and to rely more on the media. The media can give invaluable help in providing objective, many-sided information and in exposing immoral and unfair practices. The media does not shy away from controversies; thus it can be a very good ally for bioethicists. It is hard to achieve any result if locally, at one’s university or college, there are no prominent persons who recognise and support the noble efforts and goals of the bioethicist.
I, for instance, had tremendous support from our rector who, as a new broom, wanted to improve the moral level of our university. That was his main campaign slogan. He appointed me to lead the university’s ethics committee. The committee included nurses, doctors, sociologists, journalists and a priest. For about a year the committee functioned well. We were afraid of no one, and tried to be fair and consistent. Two cases might be worth mentioning that may have led to our disappearance. No one ordered the seizure of our work or threatened our existence, we just disappeared. Neither case was ethically extraordinary. One was about the much neglected university park that was full of dirt and litter. We found out that theoretically there were eight park workers on the payroll. Strangely, they all worked in offices. The other case concerned the leader of an infant unit. He applied for a top German scholarship. He was notified that his application had been accepted and that he had been granted the scholarship. However, someone from his clinic sent a forged letter under his name to the German university declining the scholarship. So this man lost the chance to study in a famous German university. Our committee looked into the problem and it became obvious that a powerful clique had blocked this doctor’s chance to spend some time abroad. Our stand in the matter shook the university, and we became a much unwanted group of people who went over the limit, and threatened the establishment and indeed the power structure itself. Our elimination was well engineered. A parallel ethics committee was set up with absolutely “reliable” people. Suddenly all the ethics cases started going to this committee, and we were totally ignored, just as if we did not exist. And we didn’t.
To fight corruption, collective efforts and actions are very important. The question, however, is how and where to recruit a strong collective force. Common goals can only be achieved if such individual bioethicists are found anywhere in the world, as are willing to combat immorality in healthcare. The Corruption Network of the International Association of Bioethics has not done anything spectacular, but it has reminded a lot of people that corruption exists, and that it is very harmful.
Before you feel sorry for the author of this paper, I must add that after my forced retirement I was given a scientific advisory status in the same medical university’s Institute of Family Medicine. And I am still there. In the meantime, I received the Gold Cross of Merit of the Hungarian Republic. I still don’t know how it could happen; nevertheless, it seems that there are not just enemies but also sympathisers around the person who dares to confront corruption. Perhaps, they are the so-called silent majority.
- Chattopadhyay S, Gillon JJ Jr, De Vries R. Where are all the bioethicists when you need them? J R Soc Med. 2012 Apr;105(4):143-6. doi 10 1258/jrsm.2012.110284
- Baker R. What is a Bioethicist? Medical College of Wisconsin blog. Milwaukee, WI:Medical College of Wisconsin; 2005 Nov 17[cited 2013 May 20]. Available from: firstname.lastname@example.org
- Grad FP. The Preamble of the Constitution of the World Health Organization. Bull World Health Organ. 2002;80(12):981-4. Epub 2003 Jan 23.
- Blasszauer B. Petty corruption in health care. J Med Ethics. 1997 Jun;23(3):133-4.
- Abbasi K. Guiding the moral vision of medicine. J R Soc Med. 2012 Apr;105(4):139. doi: 10.1258/jrsm.2012.12k028.