EDITORIALS

Integrity in medical practice

Dhanwanti Nayak, Sundar Sarukkai

DOI: https://doi.org/10.20529/IJME.2014.053


Among the many moral terms that are in common use in public discourse, “integrity” not only occurs more frequently but also seems to have less ambiguity than generic terms such as”good”, “bad” and”ethical”. The notion of integrity captures a particular state of being and the word is used to characterise people as well as events. Some examples are “She behaved with integrity”, or “She is a person with integrity”, as well as “It was an act of integrity”. In this sense, the word is a powerful expression of a particular sense of being ethical.

But what are the foundations of integrity and how do these matter to medical practice and medical discourse? Usually, when we say that a person has integrity, what we most often mean is that the person lives according to some principles and does not easily abandon them for other gains. We would argue that this definition of integrity is the most common of all the possible meanings. A person with integrity is one who sticks to her/his principles despite other pressures and temptations.

Just holding these principles, or possessing these qualities, is not necessarily enough for a person to have integrity. Integrity is something that arises when these principles are challenged, or when one is in a position where one is forced to negotiate on these principles. For example, suppose one takes a strong position on not being corrupt. If one is in urgent need of a passport and finds that it is not possible to get it unless one bribes somebody, how easily will one compromise on that principle? Integrity is the measure of resistance to such compromises. We often refer to integrity in relation to an act which one performs despite it not being the easiest or the most profitable to oneself.

The question of integrity can arise in diverse situations as in the context of everyday activities in our homes when women as mothers, wives, maids continue to cook, clean and serve the rest of the family even in the most difficult circumstances. This is an example of integrity in the household, not comprehended and always unacknowledged, because unlike the grandiose principles that men hold, these smaller principles which guide our everyday actions only make our lives more pleasant, comfortable and easy. The question of integrity arises when women have to hold onto the principles that underlie their actions even when confronted with multiple pressures to give up on them. While it may appear that the principle which underlies these actions may be patriarchal or ideological in nature, nevertheless the constant struggle to hold onto certain defining principles of one’s life captures the possibility of possessing integrity.

The idea of integrity is intuitively understood and invoked in public discourse. Even philosophical arguments about integrity often rely on this common understanding of the term. For example, Bigelow and Pargetter conclude that integrity “is the capacity to exercise strength of will(1: p 42). This may be construed as follows: to have integrity means holding onto one’s beliefs and position even when these are under attack and also holding this position consistently over time and situations. The activist, Medha Patkar is a good example of such integrity, having maintained her position on the Sardar Sarovar dam and the rehabilitation of the displaced communities for decades. It has not been the easiest or most profitable position for her to have taken, which is the case with all activists; and she has held her position with sheer strength of will. It might seem from this formulation that integrity is also related, if not equivalent, to obstinacy. We would argue that obstinacy – a characteristic which best described Gandhi according to many of his critics – has a positive side, and that is related to integrity.

McFall (2: p 7) discusses other characteristics of integrity. One of them is “coherence”, of which consistency is one kind. Consistency marks the person’s capacity to stick to her principles – and these principles have to be significant and “important”. (So, for example, some might argue that the example of women in their activities of cooking and cleaning described earlier is not really a case of integrity since the principles on which these actions rest may not be “significant” or “important” but this would be a debatable claim.) Resisting temptation is also part of coherence, a coherence between “principle and action”. McFall, too, relates “weakness of the will” to non-integrity. In our opinion, the hall-mark of consistency, in terms of coherence, is the existence of a number of other supporting principles which generate, alongside them, the synergy required for coherence.

Integrity in medical practice

In the medical field, there are fundamental ethical principles which underlie medical practice and research. Arguably, the most important of these is not to harm patients, even if you cannot help them. Given the nature of the medical domain, there are often tremendous and daily pressures on doctors and other members of the profession, to compromise on these principles. Integrity is a measure of how they stand up to these pressures, to continue to put the interests of the patient first by helping and not harming them. Sometimes, taking this sort of principled stand entails making an accurate diagnosis without putting patients through the grind of tests; at other times, it entails admitting the limits of one’s knowledge vis-à-vis a particular patient and seeking the assistance of another doctor in making a diagnosis.

Medical practice today challenges many of the fundamental principles that defined medicine in earlier times. Service was always seen as an integral part of medical practice but today treating sick patients is seen not as a service but as a profession;and this contemporary understanding of the healer’s job constitutes one of the greatest sources of pressures on doctors and nurses. Such a shift was perhaps necessary if the medical field had to become professionalised and expand its scale. There have been similar trends in other vocations such as teaching, which used to be about the love of knowledge; the teacher’s responsibility being to share it with the younger generation. The increasing professionalisation of the teaching profession has led to a change in this perception. To get back to medicine, the idea of medical practice as service is being increasingly challenged in hospitals due to the professionalisation of the field; although, given the small number of missionary and other such hospitals which continue to adhere to this principle, we cannot still totally discount it.

What are the challenges to the notion of integrity that have accompanied the shift from service-orientation to professionalisation? Professionalisation implies a shift in the context of the treatment of patients to the terms of contracts and commerce. This shift does two things: (i)it makes the act of treatment a commercial transaction, and (ii) it gives a voice to patients who can demand certain rights since they are paying for the services. While payment has always been a part of medical service, the reduction of it to a commercial transaction is a product of the neo-liberalisation of the medical profession. Paying a doctor for her services is not, in principle, like paying a shop-keeper for his service (for example, the service involved in packing groceries). The payment to a doctor, in the traditional sense, is always less than the value of the service – which is not the case in commercial transactions. But today’s commercialisation of medical treatment tends to make payment for medical service more like a commercial transaction.

Neither of the two positions is completely tenable because, while care, by its very nature, is not a completely free service, it is not a consumer good either. The conflict between service-orientation and professionalisation poses a challenge to the integrity of the practitioner. Should the doctor give into the demands of modern consumerist practices of medicine, or hold onto the ideals of medicine as service? More importantly, do young doctors today even believe that medicine is about service, rather than a business? If they do not believe that it is about service, they will experience no conflict regarding their integrity.

What are the temptations that doctors, or those in the medical profession, may fall prey to? The first is the temptation to see themselves as people who can save somebody’s life. The common observation that a doctor is seen as a god by patients, especially by those who are critically ill, is often true. How does this influence the doctor’s perception towards patients who are not critically ill? Or how does it influence the doctor’s responses to suggestions and dissent? Playing god is not an easy position to be in! Being in a position of power can slowly erode the virtues of patience, care and concern that a doctor needs. For example, the bigger a doctor is the less time s/he has to explain anything to the patient. The patient becomes somebody to whom explanations are not seen to be necessary. What does being in the position of god have to do with integrity? The challenge to integrity arises in this case because positions of power are often the medium through which principles get renegotiated, modified or even abandoned just for the sake of holding onto that power.

Along with negotiating this pitfall of being powerful, there is also an added element to the exalted status of being a healer. This has to do with the amount of money paid for this act of healing. Increasingly, as the price of medicines has shot up, patients have begun feeling deeply suspicious regarding the integrity of doctors whenever a battery of tests is ordered. The idea of carrying out these tests is to rule out certain possibilities, but from the point of view of a patient who is suffering, who has spent thousands of rupees on these tests, and who sees that no clear diagnosis has been made, it is reasonable to believe that commercial interests dictated the need to order the tests. Stories of doctors taking a percentage of fees from the diagnostic clinics which do the tests only add to this perception. Such suspicion and scepticism with regard to doctors is the by-product of an increasing belief in the lack of integrity of some doctors.

In addition to the idea and costs of medical tests, there is the aspect of prescription of drugs. When each doctor behaves as if only the drugs she/he prescribes are effective, one begins to wonder about the need for this vehemence. The challenge to the integrity of the doctor in this case comes from the pressure put on them by pharmaceutical companies and medical representatives. Junkets for prescribing a particular medication over another, enhanced commissions and kickbacks if certain medicines are prescribed even though they may be the more expensive option and other such pressures test the integrity of doctors. How many doctors take a “principled” stand on many of these issues and how many find easy rationalisations for their actions? Given the nature of their profession, we tend to believe that doctors need to take pride in being members of an educated and professional community by resisting the temptations of lucre. Being professionals has brought them decent amounts of money; their education must enable them to take a principled stand against corrupting influences.

There are many other pressures that afflict the everyday practice of medicine. The question of integrity becomes starker when it comes to doctor-patient interaction. Is it possible for doctors to spend enough time with patients given the time constraints? Can the patients be treated as individuals who deserve to know what is being done to them rather than as mannequins on whom certain actions are performed? When doctors refrain from naming conditions such as overcrowding or the provision of inferior facilities as excuses for treating patients shabbily, and attempt to do the best they can in the circumstances, the patients’ respect for them as people of integrity goes up.

Technology and integrity

Although there are many pressures on the medical profession these days, we would like to identify one specific trend which is bound to have growing repercussions on the integrity of the profession: the gradual loss of autonomy of the doctor’s self on the altar of technology. It is not an exaggeration to say that today the wisdom of machines is competing with that of the doctor. Diagnosis has been largely reduced to numbers and technological images, and the number of invasive interventions is growing by the day. The efficacy of such technologically-mediated treatment is still a matter of debate but our purpose in raising it here is to suggest that the greatest threat to the integrity of a doctor arises from the temptation to use technology as a surrogate for accepting the onus of “taking the call”.

The pressure of being a doctor is enormous, particularly when a decision has to be made on the nature of a patient’s illness. As mentioned earlier, the pressure of making a reflective diagnosis is being eased by ordering tests,the results of which are technologically mediated. Symptoms have become reduced to numbers and images as reflected in the results of various kinds of tests. The temptation to give into the technological domain is the greatest challenge to a doctor’s integrity since it is based on the belief that a (human) doctor might make a wrong diagnosis; whereas the results of tests, if carried out properly, are truthful. The excessive dependence on technology has lessened the psychological pressure on doctors but readily giving into technology, without putting up sufficient resistance through a “strong act of the will” will only harm their integrity.

The reason for this is simple. We know of a good number of patients who are totally frustrated by the doctors’ inability to discover the causes of their problems even though innumerable tests have been carried out. The doctors were unable to see beyond the results of the tests since they had sacrificed their capacity to understand the human body. Due to growing frustration, a large number of patients have adopted the practice of undergoing medical tests and interpreting the results themselves, with the help of the guidelines accompanying the test results or through the Internet. This is a symptom of the displacement of the doctor from his traditional role of being a healer and care-giver to one of being an agent of technological gadgets. Modern medicine cannot do without high-end technology but the integrity of the profession has been compromised because doctors are giving in to the temptations of technology too easily, and not resisting them enough to perform the harder task of understanding the problems of a patient.

Two other important consequences of this domination of technology are as follows. The cost of medical care has increased enormously due to the use of these technologies. Thus, the tendency to give in to this form of techno-medicine is also a way of making the profession more profitable. Secondly, the excessive dependence on machines makes the doctor lose her/his autonomy to technology. How can doctors resist technology when deep down, they are not convinced that using it is not in the best interests of patients? We are reaching a point where patients will begin to wonder who the real doctors are – the machines or the human beings in white coats? The loss of autonomy is a reflection of the loss of the “strength of will”. As mentioned above, exerting the strength of will is an indication of a capacity for integrity. When doctors lose their autonomy to the domain of technology, they lose the central core of their integrity since they are no longer autonomous and accountable for their actions. Given that the technological domain is created by an industrial complex for whom service is not the abiding principle, the over dependence on technology slowly but surely entraps doctors into the defining principles of commerce that drive technological production. Once they are sucked into this mode, they begin to lose their integrity.

References

  1. Bigelow J, Pargetter R. Integrity and autonomy. Am Phil Q. 2007 Jan;44 (1):39-49.
  2. McFall L. Integrity. Ethics. 1987;98(1):5-20.