White coated corruption
This essay documents the state of the medical profession which was once a respected line of work but today is corrupted at every level, from medical education to medical practice, and in both the private and government sectors. It calls for doctors, the government and the public to act against dishonest doctors, restore the dignity of the profession and work for the benefit of society.
India is said to have one of the most corrupt medical systems in the world (1). The situation has become so bad that patients today approach the doctor with mixed feelings – of faith and fear, of hope and hostility. This leads to a distorted doctor-patient relationship, with high chances of exploitation both ways – doctors may fleece patients and, if some lacunae are exposed in treatment, patients or their relatives may blackmail doctors (2).
Such unethical practices may no longer be cause for comment. But there are many reports of doctors actually committing crimes – distorting medical reports in medico-legal cases, providing false certificates to protect criminals, sexually assaulting their patients, and even trading in human organs (3).
It goes without saying that such criminal doctors are in a minority. Unfortunately their number seems to be increasing.
One can quote innumerable reports pointing to the inhumanity of persons in white coats. Pregnant women have been refused care because they are HIV positive. Hospital authorities have refused to release the bodies of patients who died in their care because the relatives could not afford to pay the medical bills (4). There are reports of doctors amputating the limbs of poor people at the bidding of the begging mafia. Poor people who resisted the extraction of their kidneys have reportedly been operated upon at gunpoint. The list of such practices is endless.
It starts in medical college as MBBS seats are sold for lakhs of rupees. This is merely the tip of the iceberg (5). Rampant corruption exists at every level, from medical college admissions, getting a degree, to registration with the medical council. Question papers have been leaked and “jockeys” have written medical examinations on behalf of students (6). Medical college managements are known to charge unofficial “donations” in addition to official fees. Students have been reported to bribe faculty to get good reports, and doctors have been reported to pay bribes to get registered with the state medical council (7).
New graduates quickly learn the rules of the game in government service. Within medical administrations, lucrative posts are sold to the highest bidder. Government vehicles and machinery are misused. Pharmacists perform the duties of doctors in government dispensaries. Medical supplies get diverted from the intended users. Health officers serve VIPs in order to benefit from their proximity to the powerful. Government doctors pay more attention to their private practice despite receiving non-practising allowances. They do not attend rural postings despite drawing wages from the government. Patients are forced to bribe everyone in the hospital hierarchy to get the medical treatment that is their right.
Private medical services are no better. Though medical professionals are expected to work in the interests of the public in general and of the poor in particular, all of us know that this does not always happen in practice. There are some doctors for whom making money is the only goal.
So, spurious and adulterated drugs proliferate, and licensing, accreditation and regulatory systems are subverted. Pharmacists sell their licenses to unqualified persons to run chemist shops. Even in the big cities, quacks practice without registration (8). Sex determination tests are performed though they are illegal. Doctors are known to prescribe unnecessary diagnostic tests, hazardous drugs and inappropriate surgical procedures, all for the kickbacks they receive from the healthcare industry (9). The avenues for corruption are endless.
Medical establishments work closely with drug manufacturers whose main objective is to maximise profits. Large quantities of drugs must be sold, and for this, anything goes. Doctors are the principal salespeople of drug companies and they are rewarded with research grants, gifts, lavish perquisites and foreign tours. The principal buyers are the public, who must be thoroughly medicated and vaccinated at any cost.
The government is also responsible
Though India is a welfare state, the role of the government at the centre and in the states in providing healthcare facilities is deplorable. Against the recommendations of the WHO that the total health expenditure should be 6.5% of the gross national product (GDP), India spends only 4.8% of GDP on health. Further, public health expenditure is just 1.2% of GDP, or barely 25% of the total health expenditure; the rest of the money is paid by patients directly to private doctors and hospitals (10) for whom profits may take precedence over their patients’ interests.
Even in government hospitals, medical facilities favour the well-to-do and are often beyond the reach of the poor who need them the most. The allocation of funds is often determined by the influence and manipulations of hospital authorities, and the maintenance of government hospitals is poor (11). Public funding for research and development is inadequate and whatever meagre resources are available may actually be used by people at the top to serve their own interests.
The connivance of regulators
The dubious functioning of regulatory bodies of the medical profession, namely the Medical Council of India (MCI) and the Indian Medical Association (IMA), has helped spread corruption in the profession. What can we expect if the president of the MCI, who also happens to be head of the IMA, must be removed from his post after being found guilty of dishonest practices and misuse of power (12)?
Large amounts of money can be involved in getting the MCI’s approval for setting up a private medical college. Even government medical colleges and hospitals go on reckless spending sprees before an MCI inspection. As medical and nursing colleges are income generating ventures, their owners readily offer huge bribes to the officials who matter in the establishment of such institutions.
Unfortunately, we cannot rely on justice from the legal system. When prosecutions do occur, only a small fraction of these cases reach the courts. In some cases of medical negligence, the punishment has been notional. Many cases of medical negligence are pending in various courts in the country; in the Supreme Court of India alone, there are some 3,000 cases of medical negligence (13).
By the 1990s, India had achieved the distinction of being the biggest bazaar for the sale of human organs and the sale of kidneys was described as a cottage industry in India (14). Such scandals prompted the government of India to enact the Transplantation of Human Organs Act, 1994 but the nexus of doctors and brokers involved in the sale of human organs has never been afraid of the law (15), which has been violated with impunity. For example, the Gurgaon kidney scamsters, who had been arrested for conducting illegal kidney transplants in the 1990s, evaded punishment (16) and managed to run their trade in kidneys for years, obviously with the connivance of law enforcement authorities (17). It is known that the main accused evaded arrest by bribing Delhi police officials (18).
Poverty and public ignorance
The nexus between corrupt medical professionals and politicians, bureaucrats and the police is one of the major factors multiplying medical corruption. The common man is afraid of exposing wrongdoings – the authorities may hush up the matter and target the whistleblower instead.
Public apathy and fear are also partly responsible for breeding medical corruption. Even if people come to know about unethical and illegal activities in the profession, they turn a blind eye, either because it does not concern them, or because they are afraid of the doctors. For example, many people were aware of the kidney racket but did not report the matter to law enforcing agencies fearing the consequences to themselves (19).
The organ trade has been fuelled by poverty; poverty drives people to fall into the trap set by unscrupulous elements who lure them with offers of money and jobs in exchange for a kidney. At the same time, voluntary donation of human organs is not properly promoted or utilised because of poor hospital infrastructures, inefficient transportation systems for the timely revival of organs, and a shortage of cadaveric transplant surgeons. Because of the shortage of cadaver donors, doctors, donors and patients waiting for transplants collude in illegal practices.
Social compulsions accelerate the process of medical corruption. A medical professional finds it very difficult to refuse a VIP’s request; it could mean isolation or posting to a remote area. When honest doctors cannot afford to even buy their own houses, but see that their dishonest colleagues enjoy a luxurious life, they may wonder if they are right to stick to their principles.
The task ahead
It is not too late to restrain the medical profession. This calls for a well-coordinated campaign involving doctors, the government and the public. A beginning has to be made by health professionals launching a zero tolerance assault on medical corruption. The MCI code has to be practised in letter and spirit.
The list of things that doctors must do is long. A few of them are given below.
- Refuse to take bribes.
- Collectively publicly oppose outside interference – political, bureaucratic or otherwise.
- Make a commitment to rational drug use, referral and evidence-based interventions.
- Shun erring colleagues.
- Refuse to accept any favours from pharmaceutical companies.
- Follow medical ethics and treat poor patients the same as rich ones.
The government must support and protect the interests of upright doctors. For this, it must take the following steps:
- Evolve a transparent system for the allocation of funds, for deciding the location of medical facilities and for the posting of medical personnel; this system must be insulated from political and other interference.
- Have people of integrity conduct prompt enquiries into reports of medical corruption, and take prompt action on the basis of these reports.
- Let doctors know that transgressions will be met with punishment. Medical corruption is not a crime committed in the heat of the moment. It is calculated and based on greed, and the punishment must be severe and deterrent.
- Plug the loopholes in the law on human organ transplants that enable transplant tourism and marriages for the purposes of kidney “donation”. A campaign must be started to dispel myths on cadaveric donations. The transplant programme must include a computerised national database, efficient transportation and a network of state-of-the-art transplantation centres with expert surgeons.
- Reward upright doctors to encourage role models for new entrants in the profession.
- Tackle the problem of doctors shunning government service.
- Support and protect whistleblowers who report medical corruption.
- Form a task force to defend high ethical standards in the medical profession and to fight corruption in public healthcare.
Medical corruption contributes to poverty and misery in a developing country like India. The public must contribute to efforts made by medical professionals and the government to clean up the medical system. It can do this by:
- acting as a watchdog reporting corruption or wrong doing;
- checking unscrupulous elements who blackmail doctors in cases of inadvertent lapses in medical treatment;
- being more responsive to the stress that doctors have to deal with, and
- running awareness groups to educate people on the necessity of organ donation and to encourage the framing of laws that would empower medical authorities to extract organs of unidentified and unclaimed dead bodies within the stipulated time for organ revival.
Corruption is spreading its tentacles far and wide in the medical system. To restore its noble and distinct status, all sections of society must work together to stamp out the biggest killer in the medical system – corruption.
The author thanks Dr Keerti Vardhan, Dept of Evening Studies Panjab University, Chandigarh, for assistance.
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