Greed, rationality and ethics in medicine

Autonomy (for the patient), justice (ensuring availability to all), beneficence (only for the good of the patient), and non-maleficence (not causing harm to individual or society) are the four basic principles of health care ethics.

At the core of health ethics is the sense of right and wrong; and beliefs about rights and duties. Like all domains, ethics and morals are fluid and debatable with even cultural differences too. What is moral or ethical in one culture may not be so in another one.

Ethics is dynamic. What was good ethics a hundred years ago may not be so today. Despite many controversies and discussions on the above four principles, most agree that patient autonomy is by far the most important overriding all the other considerations in event of a clash.

There are rights and duties of the doctor and there are rights and duties for the patient too. Unfortunately, the entire discourse of the governments, media, and the intelligentsia focuses on the duties of the doctor and the rights of the patient. In this process, a heartburn ensues which finally damages the profession.

Medicine, like many other professions, is a fine balance of art and science. Somebody in a malaria endemic area may choose to start anti-malarials for a fever with chills. There might be another doctor who would want an investigation to confirm malaria before starting treatment.

Both are perhaps correct and cannot undergo comparison in the binaries of 'non-academic/ academic' or 'non-commercial/commercial.' The conflicts doctors encounter in the profession many times are complex beyond the understanding of even other non-involved doctors, not to mention the laypeople.

There is a list of many do and don'ts for the doctors divided as compulsory duties, voluntary duties, unethical acts, and misconduct. There are some we are quite aware of as it makes a lot of noise in the media. Some are more subtle.

The unethical acts include advertising, printing a self-photograph on the letterhead, commissions, euthanasia, and so on. Misconduct includes sex determination tests, not maintaining records, and disclosing secrets, amongst many others.

Active euthanasia is thankfully not a big debate issue in India as in some western countries. Significantly, there are no guidelines on what the ideal charges for the patient should be. There might be official bureaucratic orders to display the consultation charges or the charges of various services provided in the hospital.

However, the ethical guidelines provided by the Medical Council do not address the charges for services in the non-public sector at an individual or institutional level. In terms of legal attacks, governmental regulations, and popular perception, the majority of the medical private sector has come in the ambit of a business model.

Thus, there is an inherent and fundamental contradiction between the service model and the business model in our medical systems. The patient in a private hospital expects the best possible services but at the most reasonable charges.

How is this balance decided? How can one calculate the rational pricing when an expert surgeon saves the life of an individual? Why should capping be applicable only to the medical sector?

The business proposition seriously mixes with humanitarian considerations in medicine and this is the main reason there is so much debate in society. Consumer protection and legal questions stay intact making the doctor always vulnerable in case of adverse outcomes. The art of medicine loses out in legal battles as the focus becomes only the guidelines and scientificity.

One goes to a five-star hotel and pays twenty times more than the nice hotel in the neighbourhood for the same idli. An individual or institute approaching a top-shot private lawyer would grumble but would happily pay a Himalayan amount of money for the services rendered.

There is a choice available to the person. The reason for dissatisfaction and heartburn in society happens because poor patients and uninsured patients forcibly go to the private sector instead of utilising the public sector.

This lack of choice should make our thinkers reflect on the state of the public services in the country or the lack of proper and rational insurance policies. Ironically, the government insurance schemes for the public sector are so poorly structured that there is enormous hesitation to take up difficult cases and generate a whole set of practices which ultimately does not benefit the health of the individual or the society. Similarly, attacking individual doctors or slapping notices on corporate hospitals for being greedy is a short-term populist method of solving issues.

When the capping comes for private institutes in the health sector, what should be the limits? To what extent business practices apply to the medical sector? The point is, these are difficult issues and there is certainly a need for wide debate instead of unthinking reactions which can only harden stances.

Ethics and morals are a very difficult subject, especially in the practice of medicine. Rationalising any unethical practice (on part of the doctors) and outright condemnation of any practice (not fitting into popular common-sense perceptions) are both wrong; and there should be perhaps an attempt to achieve a balance.

The public-private model of health should deliver the goods to all the citizens of India in an effective manner without physical or intellectual violence in society. Is there hope for such a debate?