Practising ethically in a high-tech speciality
Dr Venkat Goyal, Dr Yash Lokhandwala
Venkat Goyal and Yash lokhandwala highlight some issues in medical ethics related to cardiology
In India we feel that the system of allopathic medicine is too expensive for most of the population. In this context, the world of high-tech cardiology is a white elephant. The problem is that we do not have a better alternative. None of the prevailing local systems of medicine in India has a mechanism and infrastructure for scientific audit and infrastructure for scientific audit and continued progress. (True, these indigenous streams of medicine are popular because they are cheap and seem to adopt a more holistic approach).
As cardiologists, we are torn between our knowledge of the patient’s poverty and our pursuit for perfection. Our knowledge of the patient’s poverty and our pursuit for perfection. our dilemma here is : how does one practise cardiology within the code of medical ethics? As progressive cardiologists, we find it difficult to be consistent in our approach. Our treatment advice must be influenced by the patient’s economic status. Here we would like to highlight some issues of medical ethics particularly related to cardiology.
Developments in several areas of cardiology have occurred at a breathtaking pace in the recent past. However, the advances made in biomedical technology have both advantages and disadvantages.
Victims of the learning curve
Non-surgical, interventional cardiology techniques appear attractive. Yet they are sometimes more expensive and less effective than surgery (1). Equally important, before each endeavour or new technique is introduced, it must go through a phase of experimentation before it is confirmed to be effective. Even after it is introduced, the professional performing the technique must go through a ‘learning curve’ before s/he becomes proficient enough with the procedure to benefit the patient with a minimum of harm. Patients can suffer at both stages — till the technique is proved effective (or otherwise) and till an individual doctor becomes proficient.Non-surgical, interventional cardiology techniques appear attractive. Yet they are sometimes more expensive and less effective than surgery (1). Equally important, before each endeavour or new technique is introduced, it must go through a phase of experimentation before it is confirmed to be effective. Even after it is introduced, the professional performing the technique must go through a ‘learning curve’ before s/he becomes proficient enough with the procedure to benefit the patient with a minimum of harm. Patients can suffer at both stages – till the technique is proved effective (or otherwise) and till an individual doctor becomes proficient.
Cardiologists face temptations each time, to use ignorant, helpless and poor patients to build a reputation in a world of successful, innovative young scientists – cum – consultant cardiologists. It is incumbent upon them to avoid promoting unnecessary hospitalisations, expensive investigations, drugs of no proven benefit, and surgery of doubtful value.
Advice with many implications
Health is not just the freedom from physical illness. Nor is health care a simple matter of an ill person going to the doctor and getting treated. The doctor’s decision or advice has multiple implications for patients and their well-wishers. For instance, advice for bypass surgery can throw the household out of gear, arranging finances and human support. There are always the repercussions on the jobs of the patients and their family members.
There is no end to the level of sophistication of tertiary care facilities possible, even in India. Thus, we can save the life of a patient with advanced dilated cardiomyopathy by a heart transplant. However, though the costly, state-of-the-art procedure may be indicated on purely medical grounds, it may be highly inappropriate for that particular patient’s social, mental and financial well being. As doctors, we must put ourselves in the patient’s shoes and think of the best possible option under his or her circumstances. When problems are viewed in this manner, it is possible to that such a decision (for example, not to transplant) may not benefit the patient in the short run, but in a given situation, it may be more appropriate in the long run.
Treatment for cardiac disorders (with surgery or other interventions ) has always been one of the most costly areas in allopathic medicine. With the recent devaluation of the Indian rupee, the cost price of all imported items has increased manifold. An intracoronary stent, the cost of production of which would hardly exceed a hundred rupees, is sold for Rs. 50,000. It becomes even more difficult to advise treatments of established efficacy to our patients.
The state-sponsored health programme is unable to cater to the growing financial burden imposed by such cost escalations. Private hospitals do not and cannot help the average man in this regard. (2) Health care organisations and funding schemes are sparse and poorly organised in our country. Medical Insurance companies in India run at a loss because of patients who conceal major pre-existing conditions at the time of taking a policy. This is often abetted by doctors who hide knowledge of an illness while the policy is being finalised. There is much to be done towards developing a successful health insurance system; we need to have foresight and the right attitude, and there are many reasons why this is not so. Cardiologists have yet to justify their honesty and impartiality in this regard.
There is a growing trend of trend of indirect preferences and unethical advantages offered to cardiologists by most companies dealing with cardiology products. This competition between pharmaceutical companies ultimately takes a toll on the poor man’s pocket. The increasing number of so – called scientific conferences conducted in five star hotels serve as publicity for companies and organising doctors. (3) They are a sheer waste of time and money and should be avoided. By and by we are reduced to being puppets in the hands of commercial interests and are becoming part of a corrupt system. Cardiologists, as a group, have become addicted to sponsorships, airflights for travel and luxury tours abroad. Repeated requests from doctors to sponsors for unnecessary conferences and seminars have irreversibly damaged the reverence and respect that was given in the past to the medical profession. The creation of multiple ‘academic’ bodies and holdings multiple conferences (without any scientific content of merit) to satisfy personal egos are deplorable. This fashion in the present scenario leads to a rise in the cost of items by a margin of 30 to 50 percent of their original price.
The time has come when we have to be more truthful, sincere and committed to the task of scientific research and development (4). This is not only necessary for better understanding but also for the country’s future role and standing in the globalised economy. The indigenous development of disposables is an imperative to countering the rising costs of procedures. While in the US and Western Europe, only 10 percent of the total cost for cardiac care goes towards consumables, in India this figure is an astronomical 70 percent.
We have big job ahead or us, to set up research and development units, animal laboratories and provide a suitable environment for research. It is heartening that our defense research laboratories have taken a lead in organising the development of indigenous stents, pacemakers and catheters. We must wholeheartedly support such ventures.
The system should incorporate a mechanism to inculcate and extract scientific commitment from each doctor. In a research project, one must be sincere without manipulating the results. There are many obstacles and commitment is required at every step. The administration has to provide funds and be patient, seniors have to give due credit to their juniors, who in turn should work intelligently and sincerely. Above all, there should be a team approach and facts should be stated as they are. Perfection and excellence are self-imposed disciplines which will bear fruit for generations to come. Commitment to research in medicine may not be clause in the Hippocratic oath but we feel this has become necessary in modern medicine. The government should allot research projects to young doctors instead of enforcing a one-year rural posting before seeking admission to postgraduate courses.
The total numbers of cardiologists is small. It is still a distinguished and indispenable medical service. Since there is ample work and opportunity for everyone, we must resist the system of ‘cut’ practice (5) Senior cardiologists must set examples and be role models in this regard. We feel there should be a collective decision not to promote or partake of this unethical practice (6). This will help the patients significantly and be the right step towards restoring our lost credibility. Interpersonal relationships in the medical community have become largely commercial and indifferent (7). There is a deterioration on all fronts on code and conduct (8). We feel it is difficult to improve this situation unless a cultural renaissance is to bring back some of the lost moral values and ethical practices.
With a social responsibility that we should be accessible to our countrymen, we don’t find an effective alternative tailor-made to the needs and reach of our average fellow citizens. Less than 10 percent of our people can afford to visit a private consulting cardiologist. At an individual level it is difficult to make much impact. At the most, one can refrain from accepting perks and privileges to make the entire system more cost-effective.
- Magotra RA : Sociopolitical aspects of high-tech medical care, Issues in Medical Ethics 1997:5:11-12.
- Nagral A : The great divide : ‘private’ vs. ‘general’ patients, Issues in Medical Ethics 1998: 6:58-5
- Padmavati S : Updates and conferences, bane or benefit? Issues in Medical Ethics 1996: 4:16.
- Lokhandwala Y: ‘Evidence’ based medicine: the need for a close look at the evidence, Issues in Medical Ethics 1997: 5:126-127.
- Kale PA: An objective look at ‘cut practice’ in the medical profession, Issues in Medical Ethics 1996: 4:19-123.
- Ambulgekar R:Medical ethics and practice, Issues in Medical Ethics 1996: 4:17.
- Chinoy RF: Relations between doctors, Issues in Medical Ethics 1997: 5:105-109.
- Mechael R : Doctors, patients, manners and morals, Issues in Medical Ethics 1997: 5:19-20.