REVIEW ARTICLE ON MEDICINE AND SOCIETY
Year : 2021 | Volume
: 2 | Issue : 2 | Page : 155--158
Everyday ethical issues in Indian medical practice
Anand Bharathan, Jayapal Rajendran
Division of HPB, GI Surgery and Liver Transplantation, Sri Ramakrishna Hospital, Coimbatore, Tamil Nadu, India
Dr. Anand Bharathan
66, Sreevatsa Hill View, Kovaipudur, Coimbatore . 641 042, Tamil Nadu
|How to cite this article:|
Bharathan A, Rajendran J. Everyday ethical issues in Indian medical practice.J Med Evid 2021;2:155-158
|How to cite this URL:|
Bharathan A, Rajendran J. Everyday ethical issues in Indian medical practice. J Med Evid [serial online] 2021 [cited 2021 Oct 23 ];2:155-158
Available from: http://www.journaljme.org/text.asp?2021/2/2/155/324968
Our mandate as doctors is to alleviate suffering by preventing illnesses whenever possible and by providing appropriate medical care to patients as per established standards, irrespective of their social or financial status. Medicine is a social science and each doctor must consider herself/himself a social worker and help change the determinants of illnesses.
We consider ourselves very lucky to have trained and worked with many highly dedicated, selfless and compassionate doctors in some of the best institutions of India. We had the opportunity to learn not just surgical skills, but the ability to analyse information, be it debating published literature or dealing with ethical challenges and making fair decisions.
We chose to enter private medical practice enticed by our perception that private health care could offer a better work environment, a better staff-patient ratio that could make quality of care better, provide quicker access to higher, often evolving and expensive technology, provide earlier professional independence, less bureaucracy in getting a job in the burgeoning private hospital “industry” and perceived lack of political interference. An opportunity to get paid better, if not now, later did not drive us, though it may not be unfair to think so. Some of our perceptions seem illusory after a decade of work in India's private hospitals and form the basis of this article. The issues in which we felt most challenged and have committed ourselves to struggle with involve the social and economic dimensions of private medical practice are discussed more often in lay press, often by respected people and thus we mostly quote reputed newspaper publications.
Cost of Care in the World of Private Medical Care-Could we Moderate Cost?
The average annual income of an Indian citizen is about USD 2000 with highly inequitable distribution of wealth, implying that the vast majority of Indians are poor. The low-income group whose members earn USD 2–10 per day form the vast majority of Indians. While private health care existed for a very long time in India in small scale, Apollo hospitals initiated the first corporate hospital, built using shareholder contribution in India in 1983., Organised multispecialty care of perceived high standards became available within India. This system of corporate health care has to be profitable for the shareholders and addressing this bottom-line is essential for their existence. The 1990s saw an expansion of corporate health care with multiple other players coming into the same space and over a period of time ensured reverse brain drain of skilled expatriate Indian doctors returning to India to explore the opportunities in corporate hospitals of India. Remarkable improvements were made in the availability of care in fields such as cardiology, cardiothoracic surgery, oncology, organ transplantation and in training of Indian doctors. However, these benefits obviously came with a significant cost that most Indians could not afford. Today, about 70% of India's health care needs are addressed by this burgeoning corporate health care even as our leaders are still struggling to find the optimal method to deliver good quality health care to around 70% of Indians who are either in the poor income, low-income or middle-income group earning less than USD 2, USD 2–10 and USD 10–20 per day respectively with just over 1% of gross domestic product (GDP) allocated to public sector health care in our nation's budget., Unfortunately for patients, there is heavy consolidation and profit mongering happening in India's corporate health care. This will give few players undue dominance on everything including cost of care, which we expect to become more unaffordable for common Indian.,
The cost of health care we provide has been our greatest ethical issue in our practice. While we agree that we cannot give care free of cost or without profit in a system which is privately funded, as every step is expensive starting from purchase of often premium land, obtaining necessary permissions, construction of the building, buying costly medical equipment, bringing in expensive expatriate and often, even Indian medical workforce, an army of paramedical and support staff, we are everyday left with a question as to what is the fair price for an individual procedure or care. The corporate systems and their methods of billing are opaque, as they are private entities and cost is not in most instances regulated by law. A huge army of health care executives, often trained in world's best business schools, staff in marketing and advertising and the budgets for their pay and work, undoubtedly add significant cost to India's private health care. Hospital management also report that many essentials including power supply is obtained at premium commercial rates and add to the cost of care.
In our practice, we find that the upper-income group and the upper-middle-income group have no problem affording our services. However, the vast majority of our services are sought by the middle-income group. Ironically, only some in the lower-income group, which forms majority of Indian population even seek our inpatient services. Even for the relatively inexpensive services, we offer currently in our practice in a tier 2 city of India, our middle-income group patients corrode a significant portion of their lifetime savings. Our patients from the lower-income group report borrowing money at very high-interest rates for their treatment. Our pleas to the latter group of patients to seek care from the reasonably well-serviced government hospitals of Tamil Nadu often are not well heeded. Reasons often cited are long waiting time for operations, concern (sometimes undue) about quality of care and absence of individual attention.
We have no doubt that the cost of private health care requires moderation. Their management may not find this cause compelling as many of their leaders may not interact with patients to know their financial sources and struggles. They probably have no idea as to how people in the bottom of economic pyramid could be served profitably. Probably, that important subject, extensively researched by economists of the University of Michigan is not taught in business schools. However, we call upon doctors of this poor nation to think for this unfortunate group of patients and employ cost moderation in all ways possible. Like any good endeavor, we should start this with ourselves by asking for the most reasonable fee possible. We could be driven by the passion to empathetically serve those who are ill, show utmost compassion, and provide care that is acceptable as per the current standards rather than be motivated by our peers who could be driving a luxury car or live in a luxurious house. This way, we will build trust amongst patients and peers, our work will steadily grow and so will our reputation and income, undoubtedly. To quote Simon Sinek, “none of us want on our tombstones the last balance in our bank accounts. We want to be remembered for what we did for others.” If such an attitude is adopted by vast majority of doctors, corporations may find profiteering difficult.
We strongly believe that the current system of profit-oriented corporate health care would not be able to fully address the health care needs of vast majority of people and publicly funded insurance schemes like Ayushman Bharat that allow treatment in private hospitals are detrimental. The development of high quality, publicly funded universal health care could be only way everyone in our poor country will have equitable access to appropriate health care.
Until such universal health care is available, there are other contributions that we could make to decrease cost of care and maintain high ethical standards. We discuss some of them in the sections that follow.
There is a huge imbalance in the information we and patients have about disease processes, their evaluation, current standard of care, availability and cost of care in other centres and the results of our and other centres. Good doctors should give as much information as possible to the patient and her family about each one of the parameters listed above during a consultation. Patients should be offered opportunities to obtain second opinions in elective scenarios and in fact, we should facilitate them. In our practice, we find that this often increases their trust on us. Our role is not just making a diagnosis, giving a treatment plan, and its cost. Our role is to try and eliminate the information imbalance to the best of our abilities so that patients and their families are empowered to make their choice among the available treatment options. If our own practice does not have what could be best for the patient, we should not have any hesitation to refer her/him to the practice offering such facility. We find a disappointing lack of this effort among some doctors, while a vast majority could be silently doing their best. We know practices where the average time for each consultation is around 5 min at best. Our patients tell us instances of being advised to get admitted “immediately” or as early as possible for operations that could certainly wait a few days or even weeks. Some of these instances could be due to surgeons not wanting patients to disregard the seriousness of the problem, but this should not be done by coercing them. We call upon our peers to remain confident that by taking adequate time for consultation and by providing maximum relevant information, our practice volume, quality and beyond everything, trust over doctors will increase.
Referral fee-Appalling, Expensive Act
We know a great number of doctors whose practices have been built on high standards of care that they offer, word of mouth referrals and not based on a referral fee. Unfortunately, this disgraceful practice has extensively crept into the world of private medical care. It discredits our sacred duty of maintaining an honest relationship with both the patient and the doctor who refers the patient. It is a great menace to fair medical practice and adds significantly to cost of care as profit-seeking corporate hospitals would not share their profits with the referring doctor. The money would more likely be collected from the patient. The need to give a referral fee comes from the urgency to develop a big patient base quickly. For the hospital, this may seem an urgent priority as return on investment made is required to maintain viability. Doctors who have a choice could insist to their managements to procure the bare minimum essential hardware and teams for their work and invest in higher technology and more manpower as work grows. This lean health care model could help reduce the pressure on doctors to produce quick return on large, often unnecessary investments made by overzealous or naïve managements. With too many hospitals and too many specialist doctors crowded in tier 1 and 2 cities of India, referral fee may look the only way to attract referrals quickly and to remain viable. However, we are very certain that a good patient base could be created over a longer period by offering care of high standards with compassion and maintaining high standards of communication with referral doctors. We plead with our medical community to shun this appalling practice.
Incentives for Investigations and Defensive Medical Practice
Some hospitals provide additional incentives for performance of investigations and imaging, claiming it to be part of “fee for service” model. This could serve as a trigger for performance of unnecessary investigations, covered as a defensive medical practice that aims to avoid litigation by performing investigations that may not help make therapeutic decisions, but give a feeling to patient that treatment was effective. Amidst the committed clinicians, we often see, we are sad to see a few who do not use clinical sense to perform the least number of investigations to arrive at good treatment decisions. Avoidable escalation of cost of care along with unnecessary exposure to harmful effects of investigations like computed tomography (CT) scans occur, exemplified by the current overuse of CT scan chest in management of patients treated for COVID-19 and those who undergo operations in the COVID-19 era.
Business and promotional aggression of pharmaceutical companies often results in numerous medicines of questionable value. We find ourselves in a quagmire when patients who present for second opinion remain unconvinced about our advice to stop some unnecessary medicines. Many of them borrow money to buy them, but would not heed advice to stop those medicines due to the fear that it could be actually helping. Unless we read, trust and use published data from reputed journals to learn about new medicines and rational combinations, we could do both economic and physical harm to our patients. We suggest that as individuals and associations, we must desist from accepting any kind of favor from the insatiable pharmaceutical industry. Why should medical conferences and travel and food in them be sponsored by the industry? If the intention is to update ourselves, could we not fund it ourselves?
Changing the Determinants of Health-Alcoholism as an Example
Alcoholic liver disease is the most common indication for liver transplantation in our practice. Only a small fraction of patients with alcoholic liver disease present to us in a stage where further abstinence from alcoholism itself would suffice as treatment. Even tinier fraction is suitable for liver transplantation. Even in the process of pretransplant care, a vast majority exhaust their lifetime savings, the spouse loses her job and the resulting dip in income ends in their children dropping out of school, thus sowing the seeds for social disaster. A mathematical model developed by PGIMER, Chandigarh and AIIMS, Delhi calculated that India would lose 25 crore life years in next 40 years and 1.45% of its GDP every year due to alcohol-related illnesses. That is more than the annual health care budget of union of India. Unless the government takes this data seriously, Indians in productive age group and our social values will vanish in heartbreaking fashion.
Insensitive and short-sighted programs like funding of liver transplantation in corporate hospitals under government-funded health insurance schemes benefit only few patients, while the unrestricted sale of alcohol is run by our own governments. Most of the afflicted patients die. Our inability to initiate a struggle against alcoholism continues to be a great ethical issue in our practice. The magnitude of the problem strikes us hard daily and paralyses us. Promoting positive health by struggling against alcoholism and instilling good lifestyle habits remain a highly important and currently unaddressed part of our dream in medical practice.
The ethical issues that we discussed may not be unique to us and we could be speaking for a huge number of unheard, genuine voices in Indian medical practice. We call on the entire medical community to introspect the ethical concerns in their own practice and strive hard to solve them so that we truly live up to our mandate of promoting positive health and compassionate care for the suffering masses.
Financial support and sponsorship
Conflicts of interest
Both authors work for a private, trust hospital as part of their practice.
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