Kamal Kumar Mahawar, The ethical doctor, Harper Collins India, 2016, Paperback, 272 pages. Rs 234, ISBN-13:978-9352640096

The medical profession, more than any other, has had to constantly gaze at itself in the mirror of “ethics”, whether in praxis or in the haloed (often antiquated) oaths taken, even as it grapples with being a sustainable industry and business. A constant, willful, collective neglect of realistically addressing this paradox has created deep fault-lines in the medical profession, and this becomes the discursive topography inhabited and explored by Dr Kamal Kumar Mahawar in The ethical doctor.

Written in straightforward journalistic prose, the book aims to address a general audience but is very aware of the diversity of opinions and perspectives within the medical profession that needs to be accounted for. In each of the 12 short chapters, the author takes up a pertinent issue in the daily practice of medicine in India – for instance, the system of referrals and “cut practice”, unnecessary tests and treatment, system of touts, involvement of drug companies, quacks posing as doctors – and addresses the gap between expectations and actual practice.

Dr Mahawar, who studied medicine in India and is a bariatric surgeon in the United Kingdom, brackets off his personal choices and positioning at the beginning of the book; so that the debate can be entirely about the field. A co-founder of WebmedCentral, he brings his knowledge of medical practice and research in other countries for a comparative perspective. There is no doubt that being both an insider and outsider to the Indian medical industry gives Dr Mahawar the space and latitude to be sympathetic as well as critical, as he gives us “a snapshot of the healthcare system in India”

What does it mean to be “an ethical doctor” in India today? What does it mean to be a patient or caregiver who expects doctors to function entirely with the patient’s best interest in mind? The only way to even begin to answer these questions is to rethink the nuances and baggage of the “ethical” and to bring the pragmatic to the discussion, which is what this author sets out to do.

The writing style reveals a clear thought process. Each time an issue is taken up, there is an assessment of the lay of the land, the practices currently in use; newspaper reports of various case studies and investigations are constantly referenced, at times even dramatised in a fictional mode. Dr Mahawar’s approach to what ails and sustains the medical education, practice, and industry in India has a diagnostic tone. Within each sphere of his close scrutiny, as with the overall book, the intention is to be prescriptive. As much as the author tries to take into account the need for introspection and personal choices, the verdict for the profession is quite damming – the mapping of the last chapter “The way forward” would suffice as an example. The reforms that Dr Mahawar recommends are at every level – the Medical Council of India, the governmental policies, clinical and research regulations, drug regulatory bodies, private hospital practices. This is when one realises how arduous, almost impossible, it becomes to talk about what ethical medicine means at the level of the individual doctor or patient.

The author estimates that around 39 million families are pushed into poverty every year in India as a result of mounting healthcare expenses incurred. The reader is left in no doubt about the many vested interests, mainly financial, deeply entrenched in the medical system, and how herculean any measurable change is bound to be.

Dr Mahawar is right in insisting that many of these questions be tackled directly in the medical curriculum – the complete focus on science at the cost of the humanities has already precluded any conversation about a complex ethical schema for young doctors. Similarly, one agrees with the author that patients need to be introspective too about the choices they make when they “shop around” and decide on “famous” doctors without considering what goes into the making of this fame.

Considering that we are grappling with a plethora of dissenting voices and ethical choices, both institutional and individual, this book is a brave, prescient, and compelling argument for at least considering the idea of change, if not actually executing it. If, as patients, we have felt that everyone is out to make money at our expense when we fall ill, then the author confirms some of our fears, and thinks we pay 20% to 40% more than we should. And if, as doctors, we have felt pressurised to join the referral system and meet budgets given to us by institutions, this book gives us a way to think about personal ethics within professional bounds.

Even as the reader wants to agree with the author on the importance of all the recommended reforms, many of them concrete and specific, the real possibility of execution on such a large scale seems unlikely and gives a utopian tint to the project. Dr Mahawar anticipates and counters this by insisting “it is a practical dream that can be transformed into reality if we all worked towards it with a firm sense of purpose”. For all of our sakes, let’s hope this is true.