The physician must practise medicine fairly and justly and provide care based on the patient’s health needs without bias or engaging in discriminatory conduct on the basis of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, culture, sexual orientation, social standing, or any other factor. [1: p 1]

We draw attention to the World Medical Association’s (WMA) International Code of Medical Ethics [1] as the benchmark of medical ethics, in the face of inflammatory and discriminatory statements issued by some senior Indian doctors against Bangladeshi patients. These statements followed allegations that the Indian tricolor and Hindus had been insulted in Bangladesh. The Indian mainstream media carried these statements uncritically. The Director of Jitendra Narayan Ray Hospital, Kolkata, Dr Subhrangshu Bhakta, announced that notifications had already been issued by the hospital refusing to admit Bangladeshi patients for treatment. He claimed that Bangladesh is behaving like an enemy and that we should not help the enemy. “The nation comes first. … We hope other hospitals will support us and take similar steps, …” [2, 3] He also said that “the country is above all else ‒ that medical service may be a noble profession, but the dignity of the country was paramount.” [4]

This was reiterated in no uncertain terms by several other doctors and hospitals with the clear message that services would not be provided to patients from Bangladesh [4]. Dr Indranil Saha, a gynaecologist announced that he would stop seeing these patients, declaring “Country first, income later. I hope other doctors will do the same until the relationship is normal.” [4] It is to be noted that the good doctor makes no mention of the wellbeing of patients here, but rather of how it would affect his income. Suvendu Adhikari, Leader of the Opposition in the West Bengal Assembly, praised Dr Saha and reiterated, “I request the entire Indian medical community, businessmen and India lovers to boycott Bangladesh completely.” [4]

In this editorial, we examine how medical ethics, as enshrined in national and international codes, is considered non-negotiable on paper, but is readily subsumed under the frenzy of “nationalistic pride”. If commitments and obligations to patients can be so readily set aside for political, religious, social or other reasons, then the oath which commits healthcare professionals to ethical practice in the physician’s pledge under the National Medical Commission (NMC) [5] becomes meaningless and only reflects how poor the understanding of medical ethics is. The fact that the regulatory bodies in the country have been largely silent and passive observers of such barefaced violations is disturbing. How do these behaviours affect the ethos of healthcare in the country? What are the implications of these responses on how India is viewed by the rest of the world? We explore some of these pressing issues within the national and international frameworks governing medical ethics.

Violation of international and national codes of medical ethics

Codes of medical ethics are expected to be the guiding philosophy of practising health professionals. These codes cannot arbitrarily be set aside based on the political or social milieu of the times. When doctors commit to medical ethics, they unequivocally state their commitment to serve every person in need of care, and to respect their dignity and human rights. The WMA physician’s pledge [6] says, “I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;…” [6: p1] Many other WMA documents, such as those issued in 2017 and 2022 [7, 1], highlight the ethical obligation of physicians to minimise disruption to patient care and to cooperate in the coordination of medically indicated care with other care providers treating patients; and ensure the patients’ right to continuity and other related matters.

The Indian Medical Council reiterated, in 2016, that the prime object of the medical profession is “to render service to humanity” [5: p 2]. Importantly, at the time of registration as medical practitioners, all applicants sign a pledge that they would practise their profession with conscience and dignity and “not permit considerations of religion, nationality, race, party politics or social standing” to intervene between their duty and their patient … that the health of the patient would be the first consideration” [5: p17]. The National Council for Clinical Establishments (NCFCE) [8] also includes a specific clause against discrimination in its Charter of Patients’ Rights and Responsibilities.

Are these guiding principles for the medical profession only meant to be on paper and on hospital display boards? Should these violations not attract censure and penalties (after due process of enquiry) from the same regulatory bodies that have created these guidelines in the first place? The apathy of these bodies to such unethical declarations by healthcare providers does not bode well for a multicultural, multi-religious society such as ours. Furthermore, it jeopardises the trust of its own people in the healthcare system. The question that plagues us is: Should the regulators not be held responsible for their lack of action against unethical practices? Should they not demonstrate the ethical values prescribed for the profession? If they fail to, who will regulate the regulators?

Adverse consequences of such violations on the healthcare system

Unethical, discriminatory comments and practices can have far reaching adverse consequences. More healthcare providers and institutions may feel emboldened to take a similar stance, and patients from the targeted communities may be driven to withdraw from accessing healthcare [9]. India’s reputation as a country that welcomes patients from other countries will be tarnished. A likely drop in patient volume affects the revenue that medical tourism generates. More importantly, it deprives patients of access to quality healthcare and can aggravate ill health. Patients and families facing discrimination and exclusion will be forced to seek alternative sources, contributing to adverse physical, mental and financial consequences.

Most importantly, such events lead to the erosion of trust in the provider-patient relationship which is “largely influenced by respect for the physician and assurance of treatment, rather than objective assessments, such as the physician’s competence.” [10]

What explains such violations of fundamental medical ethics?

When faced with criticism of such ethical violations, most health professionals take recourse to excusing them as “one-off” incidents and “not by all doctors”. The resistance to introspection means that healthcare professionals could put their own socio-cultural and socio-political prejudices above the profession’s core values and principles. Healthcare providers emboldened by doctors like Bhakta, Saha and others, may publicly and privately manifest deep-rooted prejudices, earlier kept in check in deference to ethical norms.

Even as the NMC has mandated the teaching of ethical responsibilities and codes of ethical conduct through the Attitude, Ethics and Communication (AETCOM) curriculum [11] in all medical colleges, the effectiveness of such an orientation in the shaping of medical professionals warrants evaluation. How does it address the overall changing ethos of society, the lack of respect for fellow citizens, and the erosion of institutional and professional integrity?

This erosion of medical ethics may be better understood by locating it within a broader historical, as well as a contemporary socio-political context, especially on how boundaries between professional commitments and caste/religious/political/cultural alignments get blurred. A good, hard look at medical education is needed, and at the role of national and state regulatory bodies in the active fostering and advancement of a healthcare ethos of trust and reliability.

Understanding the influence of the broader socio-political context

One of the purported reasons for these discriminatory statements against Bangladeshi patients was the news that Hindus were being attacked in Bangladesh [4]. Even if Indians face concerning problems in other countries, does it justify our vengeful targeting of citizens from those countries, particularly if they are sick and vulnerable?

Can healthcare ethics, which must be upheld irrespective of wars, civil unrest, political or economic shifts, be set aside so readily? Are these core values so fragile that we can threaten to drop them whenever we feel disrespected or mistreated? Medical professionalism and ethics cannot be sacrificed at the altar of revenge and politics.

In a world where fast paced, un-verified narratives are spread on social media, emotional responses can be unchecked and spontaneous. This is especially true of those that affect our increasingly fragile nationalist pride. When doctors themselves choose to speak this language of hate and exclusion, it is an ethical breach of the worst kind.

Spreading false narratives that condemn religious and other minorities has serious repercussions on healthcare. We witnessed how the Muslim community was unfairly blamed for spreading the Covid-19 infection during the pandemic [12]. This translated into denial of healthcare in a manner quite similar to what is being threatened now against patients from Bangladesh [13]. Earlier during the Gujarat riots, discriminatory practices by doctors and even senior members of professional bodies such as the Indian Medical Association (IMA) were reported [14, 15]. An editorial in the Indian Journal of Medical Ethics of April-June 2002 had warned against the increasing polarisation among healthcare professionals along politico-religious lines: “The medical profession’s response — or lack of it — to communal violence needs to be documented and analysed. The medical profession should be concerned when one of its fraternity is involved in the carnage in Gujarat. Shouldn’t medical associations withdraw the license of Dr Togadia — and all others in the medical profession who have spoken and acted as he has?” [16] While some doctors had openly called for minorities to be “taught a lesson”, the editorial had drawn attention to medical professionalism and ethics shown by staff in public hospitals during the communal violence in 1993, noting that, “hospital staff stayed scrupulously impartial in treating those sent to them, irrespective of creed.” [16]

Importance of ethics training in medical schools

The WMA mandated the teaching of ethics in medical colleges in 1999 [17]. Earlier, Weatherall had noted that, globally, until 1994, medical ethics had been an optional subject [18]. Around the same time, Narayan et al [19] drawing upon a survey of 32 Indian medical colleges had reported that introducing medical ethics was necessary in preclinical practicals to break the barriers of compartmentalisation. It was only much later, in 2009, that bodies such as the World Health Organization (WHO) [20] began to appreciate the importance of ethics training. The introduction of AETCOM by the NMC in 2019 was an effort to integrate ethics with undergraduate medical programmes. Similarly, the National Education Policy 2020 [21] recommended the introduction of liberal arts and humanities in curricula across disciplines, a move that supports the integration of medical ethics into medical curricula.

Ways to redress and avert erosion of professional ethics and medical ethics

When there is an erosion of medical ethics in clinical practice, an urgent response is called for from medical and regulatory bodies. This has to go along with a concerted overhaul of the health system to make it more inclusive and non-discriminatory. In the current instance of statements issued by doctors and hospitals against Bangladeshi patients, the IMA had issued a statement disagreeing with this stance [22]. This is insufficient, and does not penalise doctors and hospitals in a way that would prevent similar discriminatory actions in future.

The NMC has been alarmingly quiet on the issue. In 2023, this body had stated that regulation of ethics and professional conduct would be entrusted to the respective State Medical Councils (SMC), with NMC merely acting as an appellate body for ethical issues. Concerns had been raised at the time that most SMC websites did not have a database of ethics-related complaints and their status, that states had limited capacity to implement complex policies such as the SMC Act, and that there was a risk of capture of these regulatory bodies by “professional elites” [23]. There have been calls by physicians across the world “… to strongly recommend that medical schools worldwide include Medical Ethics and Human rights as an obligatory course in their curricula.” [24: p 5]

Given the implications of violation of medical ethics in this case, there is a need for regulatory bodies to take disciplinary action against individual healthcare providers, hospitals, and their administrative bodies, for publicly refusing to treat persons of Bangladeshi nationality. This is crucial for patient safety, and to uphold the core values of medical ethics, making it clear, even at the international level, that India does not promote discriminatory practices.

While it may be true that disciplinary action has a limited impact, it is but one of the means to hold the health system accountable. It sends out a clear message that the principles of medical ethics are non-negotiable and not mere tokenism. Medical colleges need to bring these values to the centre of medical training and not just limit them to being a mandated subject. The health system is also a model for the larger society on the importance of professionalism, professional integrity, and ethics beyond individual political, religious, or social affiliations. We expect prompt and appropriate action against violations of ethical practices from our healthcare providers and regulators.

Authors: Sunita Sheel Bandewar (corresponding author — [email protected], https://orcid.org/0000-0002-4476-9984), General Secretary, Forum for Medical Ethics Society; Founding Trustee, Vidhayak Trust, INDIA; Olinda Timms ([email protected]), Division of Health and Humanities, St John’s Research Institute, St John’s Medical College, Sarjapur Road, Bengaluru 560034 INDIA; Sylvia Karpagam ([email protected]), Public health doctor and Researcher, Bengaluru, Karnataka, INDIA.

To cite: Bandewar SS, Timms O, Karpagam S. Discrimination against patients from Bangladesh: Striking at the heart of medical ethics. Indian J Med Ethics. 2025 Jan-Mar; 10(1) NS:6-9. DOI:10.20529/IJME.2025.007

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©Indian Journal of Medical Ethics 2025: Open Access and Distributed under the Creative Commons license (CC BY-NC-ND 4.0), which permits only non-commercial and non-modified sharing in any medium, provided the original author(s) and source are credited.