The practice of medicine is an ethical and moral minefield. Certain problems are universal and these have been sought to be resolved by formal ethical codes for medical professionals. However, there are always conditions, which the codes do not cover. Dr. Milind Deogaonkar (1) tries to focus attention on some situations common in India. The common underlying theme in these situations is the lack of a structured medical care system in India.

Personal choices

The problems posed by Dr Deogaonkar are of two kinds. The first kind reflects on an individual doctor’s personal choices, like self-referral, experience and communication of mishaps during treatment. In India, the ethical code of the Medical Council does not mandate against self-referral. Patients “shop around” for what is considered a suitable doctor because there is no structured system whereby a person always goes to a primary care physician as a point of first contact, except in an emergency. In this situation, most doctors in the private sector are in no position to insist on referral. This is a luxury that only established practitioners can indulge in. In the public sector, insistence on referral only inconveniences patients, as they will have to stand in one long queue merely to get an automatic endorsement to the specialty clinic that they wish to attend. In Tamil Nadu, in large public hospitals, the clerk at the outpatient counter asks the patient what the problem is and puts a stamp on the ticket to the department considered appropriate! In brief, unless we set up a clearly structured system, this is a problem that the individual doctor can do very little about.

There are many reasons why one may be tempted to do procedures in which one has little experience. Two common reasons are: to make money and to get experience. In a situation where there is grave risk to the life of the patient if the procedure is not done, and there is no chance of referring the patient to another more experienced person, it is clear that the procedure must be done. In any other situation, the solution Dr Deogaonkar suggests, of telling the patient about your experience, seems sensible and workable. His caveat that the patient may become neurotic waiting for “number one” is a little far-fetched. The “number one” idea is by and large a myth. Nowadays, there are usually a fair number of people who can perform any procedure competently. Again, this problem would be solved, by and large, if there was a structured training and treatment system where one is allowed to do procedures independently only after acquiring certified skills.

Regarding communication of mishaps, there can be no two opinions that it is essential to let the patient know what has happened.

Systemic problems

The second kind of problem posed by Dr Deogaonkar is systemic, reflecting the choices (or absence of them), which our society has made. These are: the ethics of offering expensive treatment options to poor patients, providing aggressive treatment to patients who will be an (economic) liability to families, and whistle blowing about malpractices in the medical profession.

Offering expensive and aggressive treatment options becomes a problem only when the individual rather than society has to take the financial burden. In societies where the state takes responsibility for medical care, it is easier to define what will and will not be provided. This is much easier to accept than the idea that one cannot save the life of a loved one because one lacks the means to do so. In India, at present, we are faced with this dilemma every day. Most doctors whom I have spoken to believe that one is duty-bound to advise the patient that other options are available, what the probable result of treatment will be, and leave it to them to decide if they can afford it or not. This is perhaps not the cleanest of solutions, but it is the one that comes closest to the ideal of the four pillars of medical ethics, respecting patient autonomy, non-malfeasance, beneficence, and justice.

Whistle blowing is obviously necessary to protect patient interests. It is a reflection of the world we live in that most people are afraid to blow the whistle for fear that they will be victimised. This appears to be the situation not only in India, but everywhere else as well. Perhaps this is another area where we will perforce have to wait for a better world.