Control of corruption in healthcare
Armin Ahmed, Afzal Azim
A recently published article on corruption in Indian healthcare in the BMJ has triggered a hot debate and numerous responses (1, 2, 3, 4). We do agree that corruption in Indian healthcare is a colossal issue and needs to be tackled urgently (5). However, we want to highlight that corruption in healthcare is not a local phenomenon confined to the Indian subcontinent, though India does serve as a good case study and intervention area due to the magnitude of the problem and the country’s large population (6). Good governance, strict rules, transparency and zero tolerance are some of the strategies prescribed everywhere to tackle corruption. However, those entrusted with implementing good governance and strict rules in India need to go through a process of introspection to carry out their duties in a responsible fashion. At present, it looks like a no-win situation. In this article, we recommend education in medical ethics as the major intervention for dealing with corruption in healthcare.
Effect of priming
Research on the unconscious brain has shown that human beings can be “primed” for a particular type of behaviour. Priming can be used as a strategy to cultivate honest practice among doctors. In one of their experiments, Bargh and colleagues subjected two groups of undergraduate students to different types of priming (7). One group was given a scrambled sentence test with words such as “rude”, “aggressive”, “bother” and “bold”. The other was primed with words like “polite”, “respect” and “courteous”. Following this, the students were asked to walk down the hall to receive their next assignment from the researcher.
Meanwhile, the researcher engaged in a conversation with another colleague, making the participants wait. Bargh found that the students who had been primed to be rude interrupted the conversation frequently, while those who had been primed to be polite did not interrupt at all for the given duration of the study.
In a recently published article, Bai et al showed that people who believed in a just world for others (BJW-others) had a reduced perception of intention of corruptive behaviour (8). They also showed that priming individuals for BJW- others can be effective in decreasing the intention of corruptive behaviour. In a pilot experiment, 117 undergraduate students were asked to recall and write about two incidents they felt were just (or unjust). BJW-others was significantly (p<0.05) higher after priming for a just world as compared to priming for an unjust world.
Priming with the “benefit for all” principle
Anyone who has read about the history of mankind knows that mankind evolved on the basis of certain principles. A basic principle which governs the evolution of future generations is “benefit for all”. What survives in the long run are doctrines, actions and practices that are beneficial for all, and the rest is discarded or destroyed in the process of social evolution. Corruption in healthcare is an example of a practice which is not aligned with the benefit for all principle. Emphasising this principle and its importance in social evolution can be one of the strategies for priming.
Priming healthcare professionals with a particular type of doctrine or philosophy can help to modulate their social behaviour. Advertising agencies are already taking advantage of the priming phenomenon to sell their products (9). This strategy can also be used in healthcare to promote high moral values and commitment towards one’s profession.
These purposes can be achieved by making medical ethics/medical malpractice a mandatory component of all academic programmes, continuing medical education courses and conferences. Talks, group discussions and revision classes on medical ethics can form a part of their curriculum. The best part of priming is that it can be done in organisations outside India as well. International conferences can become global centres for priming healthcare professionals with high moral values and ethical standards. International organisations can team up with Indian doctors to conduct such work at the local level. Besides this, research should be promoted in the field of corruption psychology.
Currently, the ethics curriculum in undergraduate courses deals with the larger issues of euthanasia, abortion, resource allocation to healthcare, etc., but the question of day-today medical practice is frequently neglected. A survey of 200 medical students and 136 residents in The University of New Mexico School of Medicine highlighted the need to pay attention to practical ethics and professional dilemmas during medical training (10). Another study in the UK showed that the teaching of ethics was heavily tilted in favour of the theoretical aspect, something which the students regarded as a major weakness (11).
Every society has its unique set of strengths and weaknesses. The medical ethics curriculum should be tailored according to the needs of the social structure. Table 1 presents a few areas that require relatively greater attention in the teaching of ethics at the undergraduate level in India.
The Indian healthcare system is unique due to its large size. It caters to patients from all strata of society and there is a vast variation in the patients’ paying capacity, as well as their ability to understand the implications of particular diseases and the treatment. Doctors trained in government or private medical institutions enter mainstream practice with varying attitudes and motivations. Healthcare professionals at all levels of society should be given the orientation that the healthcare system is not to be used to serve vested interests. Writing a prescription is science but healing is an art, and like all other arts, there is an element of sanctity about it.
A Sanskrit verse in one of India’s ancient sacred books describes the “benefit for all” principle in no uncertain terms: “Om, sarve bhavantu sukhinah. Sarve santu nir-aamayaah. Sarve bhadraanni pashyantu. Maa kashcid-duhkha-bhaag-bhavet” (Om, may all become Happy. May all be free from illness. May all see what is auspicious. May no one suffer). We do not seem to be aware of the value of this principle even though our ancestors realised it long ago. What we need is revision classes in ethics.
|Table 1: Some areas requiring attention in the ethics curriculum|
|1||Taking gifts from and putting oneself under an obligation to pharmaceutical companies or patients|
|2||Reporting mistakes or complications to patients and their relatives|
|3||Nepotism, granting favours (early appointments for surgery or imaging) to friends and acquaintances in government hospitals|
|4||Taking kickbacks for referring a patient|
|5||Taking kickbacks for prescribing an investigation|
|6||Having lavish meals arranged by pharmaceutical companies during academic sessions|
|7||Dealing with hostile relatives|
|8||Behaviour with a colleague|
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