Indian Journal of Medical Ethics


Wanted: ethical ‘role models’!

Sanjay Nagral

He laments the non-availabilty of ethical practitioners of medicine who can inspire undergraduates and postgraduates.

Imitation – a potent force

The process of imitation plays a very important role in moulding human behaviour. This is especially true of professions where patterns and standards are set by senior members. The medical fraternity is no exception. In the making of a young doctor, the importance of a ‘role model’, not only in fashioning his academic and professional behaviour but also in defining his ethical stance, should not be underestimated.

When an impressionable student or resident doctor enters the clinical wards, he picks up much more than just medical knowledge from his seniors and teachers. At a subconscious level, he even imitates mannerisms, style and etiquette. Somewhere along the way he picks up the ethics of his seniors. The behaviour of the chief with the patient, whether in the clinic or on the rounds, is always under intense scrutiny by his juniors. If for instance, the professor devotes a lot of time talking to his patients and explaining the need for tests, probable diagnoses and suggested treatment, his juniors are likely to do the same when they interact with patients. If, on the other hand, the chief shuns a patient who has tested positive for HIV, it is likely that his juniors will treat all patients with communicable diseases thus even when common sense dictates otherwise.

Patients : private vs general

I remember the time I joined a hospital as a house surgeon. There were two distinct classes of patients – ‘ private’ and ‘general’. I observed that it was commonplace for the chiefs to put on a smile, exchange pleasantries and spend time talking to the ‘private’ patients who were generally well-to-do and highly connected. The very same consultants would undergo a sudden transformation when in the general wards and breeze past the patients without communicating with them. I soon realised that my registrars and colleagues were doing exactly the same thing on the basis of the dominant ‘role model’ before them.

In public hospitals the inspiring teacher could show by example that the patient’s poverty does not justify any diminution in the respect to be shown to him or reduction in quality of services to be provided. By personal exertion, the teacher could demonstrate the need for greater care of this patient, who lacks an ability to complain or protest and who has nowhere else to go. The care of such patients will also be used to prove that it is possible to investigate and treat a variety of complex illnesses whilst incurring the least possible expense and without sacrificing excellence.

Prescribing practices

Rational and ethical prescribing habits are, to a great extent, related to the process of imitation. Most junior doctors form opinions about choice of drug combinations and dosage patterns merely by copying their seniors. Under the current circumstances this is especially sad since a prescription-habit, once formed, persists throughout life. And given the situation in our country, where most doctors, once they leave the medical college, learn their practical pharmacology from handouts provided by drug companies, faulty prescribing habits get transmitted from generation to generation.

Medical research

Even in the field of medical research, the ‘role model’ phenomenon has an important impact. The type of research carried out and the ethics and honesty in the research process are inculcated into juniors by example. If a professor gives a long consent form in the English language, full of medical jargon, to one of his juniors and says ‘Take the patient’s signature or thumb impression’, the young doctor learns to take ‘informed consent’ thus, even though he knows that the patient has no understanding of the language or the substance of his undertaking. A blatantly unethical act gets perpetuated. The whole idea of patients being taken for granted and used as guinea pigs to provide material for ‘publications’ has taken root because that is the prevalent culture amongst the ‘role models’.

A crying need

The corollary to all this is that just as we need good and positive ‘role models’ for academic excellence, so do we need ‘role models’ in ethics. Not only do we need large numbers of them but we also need them in the form of assertive and explicit individuals. Extremely ethical teachers, maintaining a low profile and hesitating to articulate and project their views, may not be able to influence the younger generation.

The ethical ‘role model’ has another very important part to play in the definition of ‘success’ in medical practice by showing that this bears no relation to a huge income but is, in fact, to be judged from the good done to patients, number of students of exceptional caliber trained and contribution made to the existing store of knowledge. They can also be living proof of the fact that there are ethical ways of making a decent living.

The ethical and incorruptible professor heading a state-of-the-art department will serve as an enduring source of enlightenment for his young disciples.

Medical ethics thus needs to be transformed from being yet another mundane subject in the undergraduate medical curriculum or from being an ideal but impractical ways of practising medicine to an inspiring and viable form of behaviour which brings its own rewards.

There is no better way to do this than by having individuals at the helm of the profession who have achieved success and respect whilst remaining wedded to ethics.