An important prerequisite for a society to start resolving a problem is ample discussion, and for the discussion to be meaningful it is necessary that multiple different perspectives are voiced and heard. While unethical medical practice as a topic of discussion has been around in Indian society and media for some years now, the dominant voices have been of victimised patients and defensive, parochial doctors (generally through their ‘associations’). In such a background, the new book The Ethical Doctor fills a significant vacuum by exposing readers to other important perspectives, especially of progressive practitioners and victimised (aka honestly practicing) doctors.
That author doctor Kamal Mahawar chooses to open his book with the quote “The only thing necessary for the triumph of evil is for good men to do nothing”, speaks volumes about what he intends to achieve. It also places him in the company of the ‘good men and women’ of Indian medicine who actually did not do nothing: those few doctors who have consistently and fervently made public, at great private ridicule from peers, their displeasure with several aspects of the medical profession — like doctors Arun Gadre and Abhay Shukla who wrote the recent book ‘Dissenting Diagnosis’.
One of the most troubling experiences of my professional life was seeing how viciously and irrationally the Indian medical community, my own community, reacted to the Satyameva Jayate program ‘Does Healthcare Need Healing’ in 2012. Instead of using that opportunity as a catalyst for a progressive and inclusive dialogue with the society, many prominent doctors and doctors’ associations, shunning constructive and professional criticism, resorted to personal and tasteless attacks against the individuals who made that programme. A more mature response would have been channeling the (misdirected) public anger against ‘doctors’ to an anger against the country’s healthcare ‘system’ by being open with people as to how and why medical corruption has become so rampant.
What the medical community did not do then is being done by individual doctors now. Through his book, Mahawar emphasises the significant role that citizens, politicians and bureaucrats play in the country’s medical corruption epidemic. He aptly begins by explaining the obsoleteness and occasional absurdity of the ‘code of medical ethics’ (aka Hippocratic Oath) that Indian doctors are expected to follow. People in India are not aware that the code is framed in such a language that, if interpreted as-is, almost every doctor in India will be guilty of ‘professional misconduct’ (reminding one of the Indian Penal Code’s archaic section 377, which, if interpreted word-to-word, will overnight turn millions of Indians into criminals.) The book thus starts with a potent example of how Indian doctors too are unfortunate victims of our dysfunctional sociopolitical and legal systems.
Mahawar also reminds readers how incorrect the populist tendency of invariably equating medical corruption with just doctors is, by explaining the huge influence of non-doctor players on healthcare: he talks about the often inefficient ways of governmental regulators and the often fraudulent practices of pharma companies. Here’s an excerpt:
In Western countries, the letter of the law is stronger and [pharma] companies rarely cross a line. But in India, there is no effective regulator. And instead of helping to make things better, multinational corporates have systematically used their resources to benefit from this culture. They blame their behaviour on the harsh realities of doing business in the country and then participate so effectively in market processes that the end result is a [far worse] system…
One of the most important points made in this book pertains to revamping what is called the ‘Indian medical register’ and making it more useful for the common public. Not many people are aware that the Medical Council of India (MCI) is required to maintain a register of every Indian MBBS (and further specialised) doctor and that this register is available online. The MCI, however, has not been diligent in maintaining and updating it or enabling useful search functionalities in the online version. The media should certainly follow up on this and build pressure on the concerned personnel to make the register more meaningful for the public. Ideally, just by looking in the register, patients should be able to know if the doctor they met or plan to meet indeed possesses the degrees they say they do, and when and from where those degrees were earned. Currently that’s not the situation.
Doctors often explain the difficulties of practicing ‘ethical medicine’ in India by giving the example of treating self-limiting illnesses like common cold or food poisoning. While in most cases the ideal approach would simply be to reassure the patient, suggest some home remedies and ask them to follow up, doctors will testify this is easier said than done. It is impossible for most patients in India to consider a doctor’s visit as ‘useful’ or meaningful if they don’t leave with a prescription for medicines or tests. Many doctors fear that if they do not prescribe drugs (whether or not medically indicated), the patient might be put off and never visit their clinic again.
Mahawar goes a step further and explains how a lot of unethical practice stems from additional subconscious pressures doctors face in a society, which generally equates professional success to wealth. “[Since] we [in India] respect wealth, irrespective of how it is obtained, and give it a social status, why wouldn’t everyone seek it by hook or by crook?” he asks in a chapter regarding the vicious ‘cut practice’ in Indian medicine. “In a society where honesty is considered a weakness and not respected, why would anybody aspire to be honest?”
Of course, analysing and explaining the causes of a problem do not amount to justifying its existence and Mahawar also vehemently talks about how, despite all the harsh social and political realities, many doctors generally give in to rather than resist the temptations of medical corruption. While, on the one hand, society looks down upon the ‘poor and unsuccessful’ doctor, on the other hand, the medical community looks down upon the ‘fiercely ethical’ doctor. It is very difficult for honestly practicing doctors to gain peer support and respect, and to establish themselves professionally in our country.
This book comes at an important time in a society for which it has become second nature to ‘blame the doctor’. India’s healthcare system, however, can be healed not by such blanket blaming and vengefulness, but only through an overall sociopolitical reform — after all, doctors are simply a product of their society. The book The Ethical Doctor is an important step in this direction.