C M Francis. Jaypee Brothers Medical Publishers (Pvt) Ltd) New Delhi 1993. Pages 186+Index. Rs 60)
Medical ethics remains a neglected a neglected topic in India. Its is difficult to come across a good book by an Indian author on this subject which can be used as a text by teachers and students.
A major cause for this sorry state is that medical ethics is not seriously taught in most of out-medical colleges. The indifference to ethics is so great that in the Indian editions of some famous foreign medical journals, our-editors do not reproduce the sections on ethics, preferring papers on clinical subjects and research. This indifference towards ethics has eroded the prestige, status and the moral standing of the medical profession in society. The recalcitrant attitude of medical associations in opposition to the consumer has also brought into focus the rampant unethical practices by doctors.
Pressure from the consumer movement and a section of ethical doctors is changing the situatiorl. Medical journals published from India have agreed to carry articles on ethics.
What was lacking was a good book on ethics which could be used to educate the profession and provide material for teaching and learning in the medical colleges. Dr C. M. Francis attempts to fill this gap.
The book is divided into six sections and has twenty chapters. One is struck by the range of issues covered. This is important because most of the material available on ethics in India is one of two types. Texts by prominent practising doctors appear to have been written with the intention of instructing their colleagues how tlot to get caught on the wrong side of the law. Another sizeable body of writing on medical ethics is by religious moralists, particularly by prolife Christians, for whom the ethical issues are mainly at the beginning (from conception) and the end of life. Dr Francis, on the other hand, expresses his explicit intention to educate the doctor on a wide range of issues and help the practice of ethical medicine.
The book starts with an introduction which has three chapters: some basic issues in medical ethics, teaching/learning medical ethics and codes of conduct. Dr. Francis makes the point that ‘the codes of conduct can succeed only if the profession as a whole feels responsible for their implementation. ‘His contention that ethical code is not legislation is only partially true. The Medical Council (s), created by legislation, have written codes of ethics and are duty bound to enforce these not only when there are specific complaints but suo moto as well. The impression created that codes of conduct are only of moral value without providing any legal remedy against misconduct is not correct. If the Medical Councils refuse to take action to enforce their own codes, a legal remedy to enforce them is always available. Dr. Francis provides codes as given in some famous historical works such as Atreya anushasana, Caraka samhita, Susrutasamhita and Hippocratic oath. The book would have reflected our multiculture better had it also reproduced codes from the Unani system of medicine and included the Islamic code of medical ethics.
The second section, ‘Professional and Personal’. is in three chapters and covers controversial current issues such as medical malpractice and negligence (a very informative and useful chapter), confidentiality and irrational drug therapy. As regards the second chapter it must be noted that the maintenance of medical records by general practitioners and nursing homes is very poor. There is no law in our country preventing patients from getting a copy of their medical records. Even after encouraging their patients to retain a photocopy of the hospital’s medical records over several years, the Tata Memorial Cancer-Hospital in Bombay has not witnessed any untoward physical or psychological outcome.
‘Ethics of Trust vs Ethics of Rights’ has chapters on autonomy, informed consent and rights of patients. They are concise, accurate and provide answers to practical problems. The ‘Patients’ Bill of Rights’ (pages 70-71) needs wide circulation.
‘Beginning and End of Life’ focuses on abortion, assisted reproductive technologies, cate of the terminally ill and euthanasia. Dr Francis’ religious morality comes out strongly in his treatment of the ethical issues in abortion discussed under the chapter heading of ‘Right to Life’. He contrasts rights of the foetus (‘child in the womb’) with those of the mother, paying less attention to the needs of women. This makes some of his arguments irrational and at times, factually incorrect.
‘Health Policy and Health Care’ reminds readers that medical ethics is not limited to doctor-patient relationship. It also includes health policy, distributive justice and technology. The last section is titled ‘Emerging Issues’ and dwells on research and human experimentation, alternate medicine, organ transplantation, AIDS and genetics.
This book is simply written to facilitate easy reading by the average doctor. Some terms with which medical practitioners may not be familiar-are not defined or properly explained. Vicarious responsibility of employer in cases of negligence is an example. Psychological and social privacy is another.
189 pages are insufficient for the vast range of issues covered here. Many topics need to be discussed in greater detail. Another glaring weakness of the book is absence of a list of sources from which material has been drawn. We hope that these deficiencies will be met by the author in subsequent editions.