Anand Zachariah, R Srivatsan, Susie Tharu, editors, on behalf of Christian Medical College and Anveshi Collective. Towards a critical medical practice: reflections on the dilemmas of medical culture today. Hyderabad: Orient Blackswan; 2010. Pp 392 ISBN 978-81-250-4091-0 495.00

We have been on the “threshold of transition” in our health status and healthcare system – for the past 64 years. The infant mortality rate has been reduced substantially. However, the declining sex ratio points to the widespread practice of sex selective abortion. There has been no change in the body mass index of children and women, which points towards a looming epidemic of hunger. The health infrastructure has improved but its utilisation by the poor has not. There is greater availability of state-of-the-art technologies and trained human power for treating patients. But is it relevant, affordable and based on the needs of sufferers? Are the number and quality of healthcare services – public and private- appropriate? What are the historical, political, cultural and ethical dimensions of these problems?

Towards a critical medical practice: reflections on dilemmas of medical culture today explores the answers to these questions, looking at them through the lenses of the knowledge, attitudes and experiences of medical academicians and practitioners. The book is based on a consultation on medical education; doctors concerned about the structure of medical knowledge participated in a consultative process for improvement in medical education initiated by Christian Medical College, Vellore. The non-governmental organisation Anveshi was an observer in this process. The book is a result of critical discussions about history, culture, institutions, the assumptions behind medical theory and practice, and the dimensions of a crisis of medical knowledge.

The introduction is a discussion of the ethical dilemmas in medical practice as presented by Anand Zachariah and R Srivatsan through two cases. These frame the fundamental ethical dilemmas that teachers-activists-researchers-practitioners face. Some of the questions that emerge from these two cases will have been asked by all medical providers. What was the best line of treatment: by a general physician or by an expert? What did the patient desire? Was the clinical diagnosis appropriate? Did a new protocol have to be applied for each patient? Who is responsible for avoiding exposure to the environmental causes of illness? What is to be done when social determinants like poverty are the main causes of illnesses ranging from malnutrition to depression?

The essays discuss five central themes:

• The dichotomy between modern medical knowledge, whose perspectives and content are influenced or determined by the state, and medical practice. This leads to frustration, burnout and even conflict between doctors and patients, or between government protocols and the need to tailor treatment to the patient’s needs;
• The dichotomy between medical technologies transplanted from the West, with doctors trained in their use in sophisticated tertiary care hospitals, and the doctors’ inability to apply their knowledge in less sophisticated, even rudimentary settings;
• The dichotomy between curative care services and public health services in India that sends most doctors to private hospitals in India or abroad since these are in line with their backgrounds and the investment they have made in their education;
• The dichotomy between diseases and their manifestation in India and their presentations in classical (western) medical education, that leads to innovative and inexpensive diagnostic and treatment methods; and
• The dichotomy between medical knowledge and its day-to-day practice.

While such dichotomies exist in reality, my contention is that the dilemmas remain even if one takes a patient-centric view. Some examples of such dilemmas are:

1. Do people give their consent to choose an appropriate treatment source? Do poor patients approach unqualified practitioners out of choice or out of compulsion because there is no other affordable option?
2. Whose interest is served when a patient is treated at a primary care centre by a general physician and not by an expert? Should the clinician have the autonomy to use a trial and error method that takes into account the patient’s context, in place of a well-tested clinical guideline that is developed elsewhere?
3. Who benefits from ‘cost’ reduction in a private healthcare setting? Did the private hospital ‘profit’ by cost reduction, using comparatively cheaper humanpower (such as employing paramedics, who are paid less, rather than medical staff) and treatment protocols (fewer investigations, fewer staff per patients, fewer services)?
4. Conflict of interest: What is the interest of the various stakeholders involved in deciding the types of public health measures to be introduced? This is particularly important when the model is competing with another one which has the same intention.
5. Policy and guidelines as coercive documents in practice: If a guideline generated by the government of India loses its guiding nature and becomes a mandatory ‘clinical order’ then it is certainly a violation of the principle of formal justice of applying it as per the patient’s need.

In essence, the book is a rich source of theoretical perspectives and practical examples, taking the readers back into the history of medical science and the political and cultural context of problems of public health in India. The perspective and lessons of the book are essential if our society is to avoid the pitfalls in the future course of medical technology and public health.

One may have expected more guidelines, solutions and preventive steps for health practitioners, to tackle the ethical dilemmas they face in medical practice. However, the authors have done an important job in emphasising the complexities and dilemmas of decision making in such situations, and this point is made in the title itself.