Community medical ethics
I don’t remember any discussion of ethics during my undergraduate medical education in Mumbai.
We often saw patients being investigated for research purposes, not for their own good. I remember one seriously-ill patient being subjected to all sorts of painful tests, though he was clearly going to die anyway. When I asked my seniors, they said he was an interesting case, and they might as well see what they could find out about him. I felt I was too junior to complain.
I think we learned something about ethics in the obvious differences between the two groups of teachers of that time the full-time staff and the honoraries. We used to watch them coming into the campus: the full-timers who came by bus, would walk in, simply dressed, usually on time. The honoraries drove in, in flashy cars, wearing suits. They often came late and left early, many didn’t take their teaching responsibilities seriously.
This made us respect full-timers who, on the whole, did a good job in difficult circumstances.
I remember an honorary professor who charged one of our classmates for a consultation, against the norms of professional courtesy. He took Rs.200, a large amount 20 years ago. When the student protested that he could not afford the charges, the honorary simply said that was no concern of his. We were all agitated; this incident became a topic of discussion for some time.
It was different when I did a postgraduate degree in community medicine at Christian Medical College Hospital in Vellore. Ethics was not discussed formally, but there was a certain ethical dimension to our work. Community medicine concerns poor, less privileged people and concepts like cost consciousness and the effective use of scarce resources were built into our training without being discussed specifically as ethical issues.
Some of these messages did not strike me until I entered the ‘real world’ as a community health worker. I realised then that our earlier training had given us an orientation. We could thus deal with limited resources. When we saw irrational acts whether irrational drug combinations or inappropriate use of resources – we would view them as ethical issues as well.
One example of a decision I have taken not based on medical knowledge alone concerns the treatment of tuberculosis patients. My experience has been that the decision to pursue treatment is based not just on clinical knowledge but the hard realities of life.
I remember doing everything possible to ensure that young boy completed treatment, despite the complete absence of interest from his parents. The child was cured, but when his sibling, too, feel ill, and his parents didn’t respond to my efforts, I gave up. This child died. One can only motivate up to a point.