What would you do when many of your colleagues accepted something whose very existence you found difficult to believe? How would you deal with reality when your big bosses – the principal, the director, the superintendent and the like – were all engaged in wrongdoings? Would you then be a “martyr” for a cause? Would you cope as best as you can with the faint hope that things would get better in the future? Or would you accept moral corruption, albeit slowly?

Welcome to the new world of medical malady in India – black money in white coats — “black money” meaning money obtained by dishonest means, unaccounted for and on which no income tax is paid

Truth is stranger than fiction

When you see it for the first time, you experience the uncanny feeling of facing something unbelievable. Later come the questions about the future: which direction is medicine in this country – the birthplace of one of the world’s most ancient and living systems of medicine and medical ethics – headed for?

Not very long ago, I visited a few private medical colleges in India for a faculty position. I was offered the job and the salary was negotiable. Then came the shock. The young entrepreneur sitting in the management board of the private medical college asked, “How would you like to take the salary, sir? 75:25?”

“What do you mean?” I asked.

“If you would like, we can pay you 75 per cent of your salary in cheque and 25 per cent in cash.” He further explained, “Your official income on which you will pay tax will be what you get in cheque. We can also make it 80:20 or 70:30 – it depends on how you would like it. The doctors and professors here draw the salary this way.”

I soon came to learn that this is the norm for the payment of salaries in (almost) all new private medical colleges in that state. This story was repeated in interviews in another two private medical colleges in the same and a neighbouring state. If you choose not to take the cash, your salary in cheque will not include the amount that you might have otherwise received in cash. Therefore, you have two options: “enjoy” the black money and be a part of overwhelming majority of your colleagues, or lose out financially by being “honest and isolated”. There are institutions where many doctors, specialists, super-specialist physicians and surgeons, medical teachers, professors and principals draw draw a part of their salaries as black money. The fact is that black money has found comfort, if not secure refuge, within the most noble profession of humankind.

Lost moral compass

Corruption is a reality in India. In a list of 163 countries of the world, India is placed the 74th in the corruption perception index – a ranking lower than Ghana (1). What is less known is that moral degeneration and corruption have engulfed our medical establishment from the examination system at the local college level (2) to the election of office-bearers at the medical council (3).

Let me be very clear: this article does not intend to bash Indian doctors or taint the entire medical community. Often this apprehension lies behind our collective silence not to talk about the issue. There are physicians and surgeons in all parts of India in all kinds of healthcare settings who are serving people with competence and compassion – noble aspirations and a sense of altruism are undeniably there. This is, however, unfortunately not the case with many others in our own community. Sadly, though, physicians with high moral standards are often in the back benches.

Medical practice is a big business now and healthcare is a purchasable commodity. And for every (un)necessary diagnostic lab test, the “temptation” of receiving monetary benefits (“percentage” or “cut-money”) is there. To be and to remain ethical is no easy job. In academic medicine it is not easy to bluntly hang up the telephone when you are asked to “take care” of a few examinees related to colleagues and VVIPs of all kinds. I had the good fortune to be the house physician of a professor of medicine in Kolkata who refused to follow the order of the state health minister and was subsequently fired during the infamous Emergency era. Role models of this kind are becoming rarer these days. What has vitiated the present state of affairs is that the medical establishment, by and large, appears to have lost its moral compass. Recently I was asked by a young representative of a company whether I could introduce (if possible market too!) their nutritional products in my department and hospital. To my surprise, I was told that many physicians were involved in this “service” – directly selling the high-priced nutritional products of unproven efficacy from their chambers and clinics.

Doctor, have you sold your soul?

Perhaps the worst kind of gross unethical practice in academic medicine happens around the time of inspection by the Medical Council of India (MCI) in new private medical colleges. In emergency-like frenzied activity, busloads of patients are mobilised to fill up empty wards, carloads of doctors are paraded before the inspectors (also flown in from abroad), and even instruments are hired during the period to fool the MCI inspectors. Who is in charge of – and participant in – these elaborate set-ups? Doctors, of course.

Many reputed physicians and surgeons, professors, directors and deans working in new private medical colleges fabricate and falsify records and lie to their colleagues in the MCI in order to get a medical college of questionable standards approved or recognised. I was told by a professor, a vice-principal of a government medical college and an MCI inspector, that an unbelievable amount of money (not “white”, of course) is involved in the business of getting new private medical colleges approved or recognised by the MCI. Was it a big surprise then that the former head of the MCI was removed from his post on charges of corruption (3, 4)? No. For those who are familiar with what goes on at that level of power, it was hardly a big issue.

The irony is that this organisation (MCI) – whose president was dismissed on charges of corruption – has an elaborate code of medical ethics with lofty ideals. It says, “A physician should be an upright man… He shall keep himself pure in character and … he should be modest, sober, patient, prompt in discharging his duty without anxiety; conducting himself with propriety in his profession and in all the actions of his life.” How could it happen that the regulatory body which is responsible for providing guidance moral guidance to physicians could have at its very top a corrupt man? How could it happen that the same corrupt person could also be the president of the Indian Medical Association? Is it just an exceptional case, or reflective of the general nature of state of affairs there? It appears that it is not an accident; rather, it is a general phenomenon characterised by lack of integrity and by moral decay (3, 5). What is perhaps surprising is that professional medical associations have turned a blind eye towards the fraudulent practices that plague the profession and adopted a policy of “speak no evil, see no evil, hear no evil”. This is perhaps understandable when you see a local chapter of the Indian Medical Association where all the high-profile office-bearers belong to a new private medical college and all of them draw salaries in black money.

Given the fact that corruption is a chain reaction that traps millions in poverty and misery in developing countries like India, do we not have the social responsibility to take a stand on ethical practice? Have we – the practitioners of the art of healing – gained the world and lost, if not sold, our souls? Physician, heal thyself – please.