Ethics in Healthcare

 It is hard to write about this subject in a detached manner. Medical ethics is based on the premise that doctors who provide healthcare solutions are actually dealing with human life. The premise that this is sacred gift and the person who seeks help to alleviate disease and suffering cannot be unethical in doing wrong to any fellow human being. The fundamental issue here is that historically hospitals came from places of religion and so even to this day many religious trusts consider running hospitals a sacred duty. Social organizations too think that running hospitals and providing treatment free or at a low cost is an act of charity and social welfare. The changes in this started occurring when multiple stakeholders came in the picture and the dynamics of  medical care became more complex. 

Many of my blogs in the past have touched on this subject so I will not allude to most of them. I am trying to adopt the framework of the incentives of state or sarkar, markets or bazaar and society or samaj. Let us examine each of them and see where things stand and in what way each of them relate to medical ethics.

State is defined by different forms of Government and if I were to trace the origins of healthcare, the early traditional systems had ayurveda, unani, homeopathy, siddhi, naturopathy and allopathy as branches of medical systems designed to provide healthcare.While except allopathy which was touted as "evidence based' and rational the rest were clubbed as anecdotal evidence based and therefore not authenticated by rigorous trials. However, the crucial difference between the traditional vs the allopathic system is pincer vs chopsticks approach. Modern medicine especially as practiced today is reactive and treats manifestation of disease and not the cause. It started well in a truly altruistic manner was traditionally governed by a code of ethics. The Hippocratic oath which spells out the understanding of the importance of ethical practice, of which respect for senior teachers, first do no harm and even related to one's colleagues and that of their families. Besides even the dispensing of medicines, patient confidentiality were governed by this oath. Medicine was an art and practiced by good communication, proper elicitation of clinical test signs and use of pertinent investigations to confirm the diagnosis. I do concede that this did not meet the high standards of today with the possibility of offering precise diagnosis, more predictable outcomes and better functional results. Till this time it was thought that it was possible for state to provide basic universal health coverage. 

But the things changed with advent of technology, effective medicines and advanced surgical and intensive care and in this scenario the incentives for the treating the symptoms and not the cause became paramount. The public hospitals were not having the resources or the expertise to provide advanced care and they got it from the private hospitals. These came at a cost and the incentives of private institutions to provide these were other than dictated by the Hippocratic oath. 

Besides this both the healthcare equipment companies and the pharmaceutical companies became big interest lobbies and they often sponsored clinical trials and were not averse to influence doctors to create false claims and evidence in favour of their products. 

What was the state's role in this and what could they have done differently to avoid coming to this? India started its journey to provide healthcare with lofty ideals, high on rhetoric and low on implementation. There was no attempt to invest or improve on the social determinants of healthcare and the Nehruvian top down approach was adopted. The native wisdom of the rural village economy which believed local production, consumption and mixed farming was already subverted to suit the needs of colonisers even before independence. However, instead of reviving these methods we got enamoured by Soviet style of farming where single crop mass farms were created. All of these measures combined with massive industrialization and mass use of fertilizers led to the burden of disease shifting from the communicable and vector borne diseases to non communicable disease. Metabolic diseases like Diabetes Mellitus and Non Alcoholic Fatty Liver Disease are now rampant in India and we have little or no state spending on these. So what has this got to do with Medical ethics? A lot if I can clarify in simple terms. The State wanted to provide Universal Health coverage free of cost to the poor using mechanisms of the three tier system of Primary Healthcare Centers linked to Community healthcare hospitals with basic specialities, District Hospitals in 3rd tier and second tier towns and medical colleges and hospitals in the big city. So when the state started to fail the private sector saw an opportunity. The public hospitals were places where even the middle class and poor would not want to go due to lack of hygiene, overcrowding and understaffing. The lack of emphasis on improving social determinants or preventive healthcare and the lack of a sporting culture with poor nutrition for most either due to poverty for the poor and proliferation of junk food for the rich increased the burden of Non Communicable Diseases among all sections of society. Today it is said that India continues to spend 80% of its budget on the inefficient public sector programs relating to communicable diseases like National programs on Malaria, TB etc problems which could have been solved by concentration on social determinants of health. Today when India becomes afflicted by Non communicable diseases like Diabetes, Cardiovascular ailments, metabolic disorders NAFLD, cancers of head and neck, breast and prostate and neurodegenerative diseases there is no budget in public sector for the same. Along with this the commercialisation of medical colleges and mushrooming of an unregulated private medical college contributed to the erosion of medical ethics. 

Market forces now came into play and the incentives of the private sector, pharmaceutical companies, Medical equipment manufacturers, Implant and device manufacturers are profit and in this big business interplay ethics go for a toss. The large investments in healthcare imaging and diagnostic services means that one has no choice but to look on healthcare as a business and maximise profit to ensure return on investment. Hospitals to recover cost of equipment infrastructure, doctors to recover cost and time spent in medical education. In all this comes the aspects of medical insurance which if used wisely can help reduce the cost burden by getting a wide insurance cover net and creating a regulated cost structure with a possibility of linking these to preventive health and lifestyle modification along with the use of strong clinical outcome audits. Alas, instead we have a triangle of mistrust between hospital, patient and insurance company. The incentive to fleece the insurance companies by falsifying history, hiding pre existing ailments, doing unnecessary investigations led to the rise of regulatory bodies and cashless insurance. All these have complicated matters. The market has been able to get away with this as the failure of the public sector has created a scarcity of quality care and unlike other sectors, in the healthcare sector despite Google the information asymmetry is very high and doctors play on fear psychosis to ensure they get patients. 

These two pictures tell the tale, poor insurance cover with rising cost of treatment are both creating a market where greed takes precedence over ethical treatment. So a wide net of coverage and better digital verifiable data will result in reducing trust deficit and improving quality, affordability and accessibility of Healthcare. 

The last piece of the triangle is Samaj or Society which has decayed too. The doctors who were worshipped as God are looked down upon and the bond of trust has eroded. There is anger, frustration and violence based on a lack of trust and frustration due to lack of empathy and proper communication. Many doctors cite lack of time and the business is leading them to become no touch investigation driven doctors termed in my vocabulary as 'hyposkiliacs'. The tendency to share fees from their earnings and the incentives given by pharma, implant and diagnostic companies are all contributors to this drive of erosion of medical ethics. The erosion of trust has resulted the proliferation of litigation and over defensive medical practice where doctors over investigate and operate as soon as possible lest someone operates before you. 

The solution to this problem lies in creating a better incentive and purpose to Public Healthcare based on a Universal Insurance model with a great emphasis on preventive health and improving on Social determinants of health. In Gandhi's book on Hind Swaraj he advocated Naturopathy and while I would not endorse the same using native wisdom and old grandmother remedies will certainly in most cases stand the test of First do no harm. He also advocated that doctors practicing allopathy tred to treat symptoms and give instant relief rather than try and explain patients and educate them about the cause of disease and how to prevent disease. He advocated a system where if the state took care of doctor and patients were treated free of cost the eco system could change and doctors would become more ethical. Again this is not implementable as the aspirations of most professionals in healthcare are very high. The Universal Insurance model with fair pay offs and based on incentivisation for preventive check ups and medical compliance can drive cost of healthcare down for the patients without compromising on good packages for doctors. The ultra rich can pay more and avail of doctors of their choice and market forces and societal needs can dictate the prices here. 

India is a signatory to this declaration and must try to achieve this though a three pronged approach. 

1. Improving Bijli Sadak Paani Hawaa, Nutrition and encouraging sports.
2. Universal Insurance with incentives for preventive health and compliance and disincentive for non compliance where patient bears partial cost of treatment. 
3. Improving public health hospitals with full time staff and more hospitals. Medical colleges can be a solution too. 

I hope this piece has created clarity rather than confusion since it is a while since it has been on the making.

Dr. Vispi Jokhi