Challenges in medical ethics
SP Kaushik, J Sethi, AK Saihjpal, editors. Ethics in medical and health care. Unistar Books; 2012. 216 pp. Hardcover. INR 395. ISBN 9789382246237
Ethics in medical and health care is a commendable compilation of essays that describe the ethical dilemmas and deficiencies in the healthcare scenario in India with the intention to sensitise all stakeholders to the urgent need for introspection and reform in this sector. It is a documentation of the discussions and presentations at SARATHI 2010, a national conference on ethics in healthcare organised by the University Institute of Applied Management Sciences, Punjab University in collaboration with the Senior Citizens’ Council for Human Resource Development, held at Chandigarh in 2010.
Dr SP Kaushik, an eminent professor of surgical gastroenterology, has edited the contributions and authored a few chapters. The other editors are Jitendra Sethi, professor of English, and Anil Saihjpal, professor of law from Chandigarh. Most of the authors are from hospital or pharmaceutical management with a few contributions from doctors and lawyers. The topics range from research ethics, clinical ethics and drug marketing to hospital informatics and quackery.
The chapter on malpractice by Dr Kaushik outlines the reasons for the poor quality and standards in healthcare and ethical practice. Dr Sandhu describes misconduct and corrupt behaviour. In separate chapters, specialities such as surgery and anaesthesia are scoped in depth, with citations of ethical lapses in current practice, and the systemic failure of oversight mechanisms or peer review in addressing them. The discussion on regulation and legislation deals with some amendments and broad application of the laws. The Medical Termination of Pregnancy Act, 1971, The Transplantation of Human Organs Act, 1994, and the Consumer Protection Act, 1986, are points of focus along with their shortcomings.
The three essays on research ethics and clinical trials predictably paint a dismal and unpromising picture of this area with statistics and reports of unethical trials. There is much described about unethical marketing practices of pharmaceutical companies with lurid stories about the nexus with doctors. It includes an interesting detailed breakdown of prices of commonly used drugs, the shocking retail mark-up and a comparison of brand and generic prices. The discussion on the Patents Act sketches out the areas of special interest for a country like India with inadequate access to cost-effective care.
The two chapters on hospital information systems and information management focus on the unaddressed issues of patient data management and use. Aside from issues of confidentiality and consent, these chapters also cover the possibility of unplanned use of data, training of all cadres of healthcare personnel on protection of information, and autonomy of the patient. Insurance companies and employers may gain access to integrated health delivery systems, leading to violation of privacy – an area which begs for regulation. Similarly, the topic on E-Health targets validity and confidentiality issues related to online health information, databases and health services.
There is a very interesting focus on the history and evolution of the practice of ‘quackery’ in a chapter strangely titled “Roadside Romeos”. Towards the end of the book is an essay on hospital waste that shares alarming statistics of re-use of disposables, and another that outlines arguments for and against euthanasia.
With medical practice and healthcare such a vast and complex field, it is no simple task to include or address all of the ethical issues that are encountered therein. This book makes a start in expressing and acknowledging the size of some of the problems we face in the Indian context. It is not difficult reading, in spite of the subject, as the format is short essays and chapters. The downside is that there tends to be only superficial description of some extremely complex and nuanced situations in healthcare. In some instances, such cursory handling of controversial ethical issues can be misleading. The discussion on stem cell therapy offers the impression that it is already the standard of care in non-haematopoietic applications. There is an erroneous remark that the ministry of tourism advertises kidney transplantation on its website. Some repetitions on general principles of ethics and research ethics in different chapters could have been avoided.
This book is an excellent first read for healthcare personnel to get a bird’s eye view of some of the ethical dilemmas encountered by the medical profession in India. It could sensitise patients and doctors, as well as nurses, technicians, medical administrators, the pharmaceutical industry and health planners to the high expectations of ethical behaviour in health care and health delivery, and expose areas of corrupt practice or misconduct in urgent need of reform and regulation.