Medical ethics and practice
There is an unwritten code of conduct for every profession and the medical profession is no exception The oath handed down by Hippocrates is well known. (1) The Maharashtra Medical Council( MMC) is particular to see that every doctor follows the code of conduct and insists on doctors on following it.
Even in the present age of advertisement, the medical profession does not allow publicity or advertisement or permit distinction on the grounds of speciality. Doctors are cautioned against the use of adjectives like ‘the only expert’, ‘gold medalist’ and news reports such as ‘I removed a tumour weighing 20 kgs from abdomen’. Doctors are also prohibited from giving their names, addresses and speciality in the yellow pages of the telephone directory in bold letters.
Every year the number of qualified doctors in the profession is on the increase. Consequently: the spirit of cut-throat competition seems to have assailed this profession as well. The well known actor, Dr. Shriram Lagu, appeared in an advertisement of Chyavanprash (an Ayurvedic preparation) some years ago. Disciplinary action was taken and his registration was cancelled. Doctors are pulled up for such violations and usually the matter treated as closed after the doctor concerned apologises and assures the council that he will not repeat the offense. Of late, in most cases of such violations regarding publicity, the offending doctors are merely warned. In many cases there is a dearth of evidence or convenient explanations are tendered by offending doctors and accepted by the MCI.
Another practice which violates the ethical code is the prescription of medicines on letter pads provided by drug shops. Nearly 40% of doctors still use such prescription pads. If a complaint to MMC is lodged with proof, the concerned doctor can be taken to task.
The code permits advertisement of the inauguration of a hospital, shifting of hospital and facilities available at a hospital, but the advertisement has to have a prescribed format and size. Nobody observes this code these days. An escape route is found by inserting a large advertisement said to be issued by ‘well wishers’.
The term ‘cut practice’ denotes payment of a commission by the specialist to general practitioner sending him the patient. As much as 20% of the total expenses incurred by the patient for treatment may be thus transferred to the general practitioner. This practice is on the increase and our profession is being ignobly commercialised. In cities like Bombay, an ordinary MBBS doctor earns quite a lot in this fashion and, to boot, he escapes accountability.
Unnecessary hospitalisation, tests, drugs, surgery
Doctors who have their own nursing homes tend to admit patients, who could do well without it, on the principle that it is better to admit patients and earn money rather than keep beds empty. It is not qualitatively different from running a lodge. In any event, the patient is paid little attention and is not treated as he ought to be.
Many doctors, particularly those owning large nursing homes, are desperately keen that their sons or daughters become doctors. If the offspring fails to get admission in a reputed medical college on merit, the parent pays huge donations to ensure admission even to a substandard private medical college. The future of their nursing home-cum-lodging-boarding establishment is ensured.
Unnecessary tests on blood, urine and other bodily fluids are another form of unethical practice. Some doctors insist that their patients go only to a particular pathologist. Accuracy in the report is not the criterion for such a choice. It is a shame that earning commission and exploiting the patient are the primary motives.
One has to sadly confess that with rapid advancement in technology, doctors have further means at their disposal to extract money from their patients. In addition to the traditional unnecessary requests for X-ray films are added those for ultrasound scan, computerised tomography, magnetic resonance studies and so on. In most cases such studies make no difference to the treatment. The doctor insists on one or all these ‘just for fashion’ and to ‘earn’ more money.
When a patient complains of pain in the chest, irrespective of the cause, the doctor asks for an ECG (electrocardiogram), echo-cardiography and, ultimately, coronary angiography as a routine.
Sex determination of a child before birth is possible through amniocentesis or foetal sonography. Amniocentesis for sex determination before birth was banned in this state when it was seen that 7,999 out of 8,000 abortions were performed just because amniocentesis showed a female foetus. It is shocking that lady doctors too lend themselves to such practices.
Psychiatrists often suggest ECT (electro-convulsive therapy) in patients of unsound mind when it is not really indicated. .
The thrust of our efforts should be to bring the patient back to normal using the simplest form of treatment. The urge to make a fast buck and to make a show that something extraordinary has been done make doctors administer dramatic and expensive therapy, impoverishing the patient and, at times, causing physical harm as well.
Prescribing a long list of drugs has become very common, particularly among specialists. Unnecessary use of pain killers, antibiotics, tonics and corticosteroids is equally common. Specialists are careful to ensure that the cost of medicine is more than double the consultation fee in order to make the latter appear relatively insignificant. To do so they often prescribe drugs which are not required.
Diseases like polio, tetanus, measles, whooping cough and diphtheria are prevented by effective vaccination. These vaccines must be stored in a refrigerator to ensure efficacy. Many doctors who have no refrigerator for preserving the vaccine keep them at room temperature. A vaccine which has lost potency is not useful in prevention of diseases. In fact, this gives a false sense of protection from disease and the child suffers from the disease despite receiving immunisation. This is not only violation of code but also gross criminal negligence.
Surgical operations such as removal of tonsils and adenoids, vermiform appendix, Caesarean section are done deliberately when not indicated to extract money.
Whilst specialists are guilty of the practices referred to above, general practitioners make easy money by giving unnecessary injections or intravenous fluids. In fact, injections have no advantage over medicine given by mouth when absorption through the gastrointestinal system is unimpaired. Doctors seek refuge in the excuse that patients demand injections under the impression that if they are so treated, their illness will disappear magically and that they will not visit doctors who refuse to give them injections/ saline on personal demand. We must remember that this is because of their ignorance and faulty education on matters of health. Instead of deliberately misguiding the patient and stressing the importance of injections and saline even when not required, it is our responsibility to educate them on the dangers of injection and efficacy of oral therapy. (See essay by Dr. H. V. Wyatt on page 14 of this issue.)
The doctor and the drug industry
Many pharmaceutical companies offer attractive gifts like television sets and refrigerators to doctors if they prescribe drugs manufactured by them. This amounts to nothing less than bribery. There are also indirect ways of bribing the doctor. The dinners or lunches hosted by a pharmaceutical company in five-star hotels during seminars and symposia are examples.
Responsibilities of the doctor towards his patients
A doctor should serve as a beacon to society. Most believe that whatever the doctor advises is for their good. Women and young adults tell the doctor of events which they would not disclose to their spouses or parents because they believe in him and they expect relief from pain and disease. There is a feeling that God looks after you after death but the doctor does so during life. It is, thus, a betrayal of trust as well when a doctor’s sole aim is to enrich himself at the cost of the patient.
There is a great need for implementing the prescribed code of conduct for doctors because the morals of our profession are fast deteriorating.
Other medical disciplines
The above discussion is in respect of doctors with the basic qualification of MBBS, practicing modern medicine. There is no provision in the MMC for punishing quacks or Registered Medical Practitioners (RMP).
Unani hakims, Ayurved vaidyas, and diplomates or bachelors in homeopathic medicine administer not only their own medicines but also prescribe such drugs as corticosteroids and antibiotics, despite ignorance of their adverse effects. It is sad that only those with the MBBS degree are expected to observe a code of conduct whilst quacks, RMP remain outside the provision of the code.
- Hippocrates: The Hippocratic oath. Medical Ethics 1994; 1: 12.
Life according to knowledge is not that which makes men act rightly and be happy, not even if all the sciences be included but… this has to do with one science only, that of good and evil. For, let me ask you… whether if you take away this science from all the rest, medicine will not equally give health?
And yet… none of these things will be well or beneficially done, if the science of the good be wanting.
Plato (427?-347 BC) in Charmides 174. B (translated by Benjamin Jowett)