Indian Journal of Medical Ethics


Self reulation or external control?

Amar Jesani

There is a need for establishing some control, ceiling, regulations on the cost of health care in general and fees charged by doctors in particular.

A powerful argument has been provided by the thirteenth report of a committee of the upper house of Parliament (1). The committee commented on the arbitrariness in charging fees, failure on the part of doctors to provide patients with details on their fees and the complete absence of transparency regarding financial dealings between doctor and patient. The committee has made a mild recommendation : each doctor should notify his/her fees to the Medical Council of India and the Council, in turn, should publish such a schedule and make it available to the public at large. The Council is also charged with the responsibility of ensuring that no doctor charges fees more than those notified. Subsequently, the parliamentary committees have recommended a ceiling on the fees charged by doctors and lawyers.

There is a very strong case for bringing down the cost of health care to consumers. Since 70 to 80% of health humanpower and infrastructure is in the private sector, where the costs are very high, the pressure to lower charges will, of course, be on this sector. Doctors there have already started contesting the idea but can an ethical doctor remain oblivious to what health care is costing the people? Medical Ethics has repeatedly drawn attention to the commercialisation of medical care which is giving rise to unethical practices (fee-splitting, failure to admit seriously ill patients to hospital till a large sum is deposited and so, on). These have led to the pauperisation of the already poor. They cannot afford the cost but have no alternative to payment when rendered vulnerable by illness. Some sell their small holdings of land, others the scanty jewelry adorning mother or wife. Yet others borrow at exhorbitant rates of interest and land themselves into ever-deepening debt.

This is a larger issue, but surely does not lie outside the framework of medical ethic which is not confined only to the doctor-patient relationship. It has equal relevance to organisation of the system for maintenance of health and medical care. If the profession remains insensitive and takes no step to reduce financial barriers in the way of people’s access to health care, society at large will, inevitably, step in and establish control over commercial exploitation by the profession. This has happened in all societies, including that in USA. The rulings laid down by ihe parliamentaty committees in Delhi is a step in this direction.

If there is social and ethical justification to reduce the cost of health care, how should it be done without compromising the professional independence of doctors? In USA. third party payment (by private insurance, state funded Medicare and Medicaid and other organisations) ensures such regulation. These agencies lay down the maximum costs permitted in the treatment of each illness and will not pay anything in excess. Since they command considerable influence, they have forced the medical profession to bow to their directives. It is no coincidence that the present debate in India has a backdrop of the release of the Malhotra committee report recommending opening up of the Indian insurance sector (including health insurance) to private Indian and international agencies. Doctors in the private sector, for whom their own market is sacrosanct, will find it difficult to offer a credible defense against the control on their economic; and for the first time even on their medical activities, by the profithungry private insurance companies.

Would it not be better for the profession to regulate itself and ensure for the common people medical care at a reasonable cost?


  1. Government of India: Thirteenth Report: Committee on Subordinute Legislution. New Delhi, Lok Sabha Secretariat. 1994 pg. 5-7.