The foundations of modern medicine were laid down 2000 years ago in Greece. It was the ingenuity of one man Hippocrates- who stressed careful clinical examination, documentation and scientific logic that delivered medicine from quackery and propelled it towards becoming an art and a science. Hippocrates also advised on how a doctor should behave in society and bound all his colleagues- for ages to come- by an oath. This oath continues to be sworn by medical graduates even today.
What is this oath? If analysed logically, it is simply a set of rules which requires us to be compassionate and honest with our patients and work in their interest. It forbids us from taking undue privileges in the course of treating our patients. It implores us to guard our art and our science, to improve upon it and to pass it on to future generations. It sets guidelines for our behaviour and conduct with our colleagues.
Medical ethics have evolved around the guidelines in the oath. As long as the intention of medical science is to care for and heal the sick, the significance of the spirit of the oath will remain unchanged.
Society is in a continuous state of evolution and change. What was forbidden 2000 years ago, on religious, moral and ethical grounds is accepted today. ‘I shall not give a pessary to a woman to cause abortion, ‘ was sacrosanct in the days of Hippocrates. Termination of pregnancy is now acceptable in India on social, legal, medical and humanitarian grounds. This reflects a change in practice based on social and demographic pressures. Such pressures can, however, be double-edged. Along with the vastly increased coverage of medical practices by the media and the greed for riches, they are corroding medical ethics and practice as never before.
Who is to blame? Society? The legal system? Ourselves?
A critical analysis of the situation as it prevails today shows that we, in the profession, are to blame. Self-interest is paramount. We sacrifice ethics readily to perpetuate our interests.
We watch our juniors being exploited by the State in silence. A resident doctor works harder and is paid much less than a class IV employee in our public hospitals. The ability and work of our junior colleague become less important than those of a peon in the eyes of those in authority and yet, we remain unmoved. Not wanting to antagonise the State or the public, we do not even utter a word of sympathy. Instead, we go around explaining the injustice our junior is doing to the public when he strikes work. Are we not bending ethics to suit what we want?
Yes, we do have a responsibility to society but don’t we also have a responsibility towards our juniors? Should we sacrifice their interest every time they strike work? Is this the baptism they get on their entry into the medical profession- a constant exploitation in the name of service? ‘I went through this, so must you. ‘ This oft repeated explanation from a senior doctor to the residents is no justification at all.
Medicine is based on the tripod of service, research and education and ethics govern all three. A doctor has to be a physician, a scientist and a teacher to guarantee service and progress.
What are the ethics that govern the teacher in us? Medicine is a science and an art that has to be passed on from the teacher to the pupil. A cardiac murmur, the signs of inflammation or the diagnosis of a rare disease have to be lovingly taught. The craft of surgery has to be patiently passed on over years. A delicate balance has to be maintained between protecting our commitment to patient care and medical education.
The intricacies involved are best understood by the doctors themselves but politicians and businessmen feel otherwise. Whilst it is possible to teach medicine using the blackboard and models, they have erected medical colleges charging capitation fees all over the country.
What did we do? We bent over backward to recognise them and in doing so, further lowered the standards of medical education in the country.
Were we not ethically bound to prevent this sorry state? When merit should be the sole criterion for entry into medical colleges, we have allowed an undeserving son of a rich man to buy his way into an MBBS degree and have disallowed a deserving and motivated child of a poor person the privilege of becoming a doctor.
What made the authorities place the medical profession under this Act? Was it the corrosion of our ethics? Were doctors perceived as having turned into reckless, rapacious monsters? Were we seen as behaving like traders? At least this is what our parliamentarians, Supreme Court judges and journalists feel. So by a single Act of Parliament, we were equated with traders in our country. This has slashed the fine thread of faith between us and our patients. A recent judgement from the Supreme Court asks us to exercise ‘reasonable care’ in dealing with our patients. What is ‘reasonable care’? We do not know. Our teachers taught us to care and do our best for all our patients irrespective of caste or class. If quick justice was one of the main reasons to put doctors under the CPA, I wonder if the judges would be willing to give up their ten weeks of yearly vacation to clear our judicial backlog.
The act has brought us at a crossroad of patients’ interests and the protection of our reputation. Defensive medicine, as practised using western standards, may become the norm for ‘reasonable care’. If this comes to pass, the costs of medical care will pass beyond the reach of most of those in the middle class.
The average patient continues to have faith in his doctor and we are using our clinical skills to the utmost, to deliver quick, good quality service at a reasonable cost. The CPA now lurks in our minds. There is also a nagging anxiety about possible vindictive behaviour by some patient. The CPA may make it impossible for us to restore the doctor-patient relationship of yore. This will hurt the patients and society more than it will the doctors. The redeeming factor will be the force of medical ethics that requires us to treat our patients with the same sincerity, compassion and care as before.
This has been discussed and written about at length. A major part of the Hippocratic oath and the enunciated principles of medical ethics, however, refer to the doctor-doctor relationship. A physician is a part of society and, like everyone else, has been caught in the pursuit of self-glory; prestige and materialistic gain. I do not see anything wrong in this. A physician must have a comfortable living standard for his family and himself. He is an important, learned member of the society and is entitled to the best that society has to offer.
But somewhere? during this pursuit, has he trampled upon the legitimate rights and opportunities of his colleagues? That is the crux of the problem. If the doctor-patient relationship is at a low ebb, the doctor-doctor relationship has touched rock bottom. The exploitation of fellow professionals is discouraging new entrants into the field to such an extent that they search for greener pastures abroad. The loss of highly qualified colleagues to countries such as the United Kingdom, America, Australia, Canada and the middle East is reaching alarming proportions. It is time the profession devises methods to reverse this brain drain. It is our ethical duty to our country to do so.
Monetary exploitation of a doctor by a doctor is a reality today. Has it made the doctor happy? Is the medical profession satisfied with the state of affairs today? Do we, in our moments of solitude, believe in what we are doing? Discussions on this subject invariably lead to justification of present conduct. Do these arguments sound convincing? Definitely not.
We are behaving no better than middle-men. A middle-man is, at least, open enough and both parties willingly pay him his share. If we have the conviction of our actions, let us muster the courage to come out into the open. Let us announce the system of split fees and unload the guilt from our consciences. There will be an emotional catharsis as we boldly say to society: ‘We split fees because we believe in it and as it is our means of livelihood.’ However, if we are unwilling to do so, it is time we find alternative means for bettering our standards and not depend on exploiting our colleagues.
Will ethics become extinct? Will the Hippocratic oath become irrelevant? I believe the answer is an emphatic ‘No!’ Ethics is enshrined in the essence of our profession and is responsible for its nobility. In ethics lie the virtues of our profession. The physician without ethics lacks a soul. It is, then, even more important to guard it with all our might, against the onslaught by the forces of rampant commercialism.
There are important moments in the history of a profession. We see them as landmarks of achievement, discovery and social contribution. Our profession has had many such glorious moments. The observations of Ignaz Semmelweis and Joseph Lister are of no less importance than those of an Einstein. The nobility of Louis Pasteur or Albert Schweitzer is matched by few in any other profession. We have, thus, inherited a glorious tradition. It is due to the efforts of the likes of these giants that we owe the reverence in which our patients hold us. When they confide their innermost thoughts in us, and trust us to heal, wipe tears and bring back smiles, they do so out of faith born of that tradition. Let us not betray that faith. If we hold fast to the ethical principles that govern our profession, we shall have the means for performing our duties without, in any way, letting down our forebears.
The prophetic words of Hippocrates must resound in our ears all the time. ‘Now if I keep this oath and break it not, may I enjoy honour in my life and art, among all men for all times. But if I transgress and forswear myself, may the opposite befall me.’
(This essay was awarded the Dr. C. T. Thakkar Oration Award by the Indian Medical Association. Reproduced with permission from the Souvenir of 9th Annual Conference of the Bombay West Suburban Branch of the Indian Medical Association.)