HANDBOOK OF MEDICAL ETHICS

Historical and legal approaches
On earlier pages we focussed attention on the declining ethical standards of the medical profession. We drew the attention of our readers to various historical guidelines, dictums, oaths and writings in the hope of stimulating our colleagues into serious introspection.

Viewing the situation from another angle, we showed how the state and judiciary have been intervening increasingly in matters related to the practice of medicine and have pointed out how this follows failure on the part of the profession to regulate itself. The message here is, ‘Police yourself or be policed by others. ’ We emphasised the legal aspects of medical ethics.

The above approaches certainly have their place but also have their limitations. The repeated invocation of archival material tends to create an impression that ethical edicts are merely of historical significance and are irrelevant today. Some of the historical texts on medical ethics are based on morality, at times even bordering on the spiritual or the religious. This could be a hindrance to wide acceptance. On the other hand, too much emphasis on the legal aspects creates a sense of enforcement with resultant alienation.

It is obvious that no single approach in the process of popularisation of medical ethics will serve the purpose. We need to discuss various other aspects of ethics.

Social obligation
In this essay we put forward the view that besides the moral and legal aspects, ethics has a strong social facet. In other words ethics is not only a moral and legal obligation but is, in a sense, a social responsibility. Given the right emphasis, this impetus to ethical behaviour could be a very potent force both individually and for the ethics movement as a whole.

In an effort to clarify this point we start with a look at the ‘generation gap’ in ethical behaviour that is obvious to any observer of the medical scene in this country. Overall, the generation of doctors in India before and soon after independence held ethical values of high standard. Honesty, sincerity, academic excellence and service to the poor were of paramount importance. In part, this was a result of the general political and social ethos of the times. It was an era of ‘idealism’ and many amongst the medical profession were also deeply involved in the nationalist movement. Many shades of political thought from Gandhism and radical socialism to religious nationalism found followers in the medical profession and very often_ determined their actions and, therefore, their ethical values. For example, one does not normally talk of Dr. Kotnis for his ethical values but his work amongst the victims of the war in China was inspiring from an ethical point of view. Thus the ethical stance of the profession was heavily influenced by the politics of the times.

This trend even spilled over into the seventies and the eighties when several young doctors, again under the influence of political ideology, gave up lucrative careers to carry out experiments in alternative ways of practising medicine, especially in rural India. The common thread in many of these ventures was an effort to practise a ‘pro- people’ type of medicine. This inclination waned in the eighties and was drastically reduced in the nineties but can still be identified.

Surely this waning has something to do with the overall retreat from ideology and the increasing influence of market and commercial values in society in general and the medical profession in particular. The commitment to ethical behavior, which arose in no small measure from a broader social commitment, has declined and is now at an all time low. The scandals surrounding the unethical behaviour of medical professionals that have hit the headlines in the past few years are an eloquent testimony to the growing hold of the urge to get rich quickly.

This, of course, parallels ( or is a result of) the increased importance of such values in the entire socio- political system. One suspects that a similar sequence must have been seen in other developing countries.

The change described above is not surprising. Many have emphasised that the behavioral value system of any society at any particular time is heavily influenced by the socio- political ethos and dominant political thought. There are several examples of how such a phenomenon has been abused by those in political power to subvert the medical profession to perform acts which, to say the least, are unethical. The collusion of many physicians, scientists and public health officials with the Nazi movement to participate willingly in inhuman experiments, torture and killing is well known.

The influence of politics
Political ideology can totally hijack the ethics of any profession often by force but, at times, even by brainwashing and in that sense can, therefore, be double edged. It is necessary to counter malevolent political influence. We are not for a moment suggesting the total politicisation of the ethics movement but recommend that it addresses issues beyond the moral and the legal.

Here is an example. The recent commercialisation of medical education in colleges levying capitation fees has been an important~ issue for the community of medical students. The very concept that the rich can buy a seat in a medical college is a gross violation of social ethics. What would be the impact on ethical values when students graduating from these colleges try to recover from their patients the large sums spent on their own education? The students’ movements against these capitation colleges could, in fact, have been integrated with the movement for ethical practice.

A doctor’s responsibility to society
Why is it binding on a young physician to discharge his duties ethically? Apart from the moral and legal reasons for doing so, ethical practice is essential because society has contributed greatly to the education of each doctor in many ways and it is binding upon him to repay this debt. Given the poverty in our country, high fees charged by doctors are also reprehensible as they are a form of social exploitation.

Medical ethics - a broader concept
There exist in many countries, including India, movements on drug policy which address themselves to issues such as promotion of irrational drugs and banned drugs. On the one hand they offer constructive criticism on state policy in this field, on the other they are trying to promote a scientific and rational method of practising medicine.

This and other similar movements should be integrated into the general effort at improving medical ethics in the country. Discrimination in health care and lack of access to health care facilities which are of particular relevance to the third world situation could also become an important part and parcel of the movement. The struggle for medical ethics should become not just a moral crusade but a larger movement for a more humane, rational and equitable system of medicine. This may, necessarily, mean a certain politicisation. Implicit in this approach is the fact that we will also be gaining allies outside the medical profession. This could help by injecting much needed vigour.

This approach is open to criticism. It could be argued that there may be a loss of focus. The ill effects of politicisation may also need serious consideration. The ethics camp may be split by differences on socio- political perceptions.

The fact remains that we must constantly strive to respond to various sociopolitical issues and movements failing which we will be guilty of isolationism. The best means for achieving this goal without diluting our principal agenda of medical ethics could be the subject for further discussion. For those of us who have gravitated to the ethics movement from streams of political thought, this is a challenge in itself.