Guest article by Dr. Sumit Ray, senior consultant & vice-chairperson, Critical Care & Emergency Medicine, Sir Gangaram Hospital, New Delhi.
When your doctor prescribes a medicine saying it’s the best for you, are you sure it’s in your best interest, or was he taken on a luxury cruise last summer by the pharmaceutical company which sells that medication? If he refers you to a particular hospital or diagnostic facility, is it your best interest he has in mind? Or is he getting a “cut” or commission (euphemistically called “facilitation fees”) for it?
Doctors might say they cannot be bought with expensive meals and holidays but there is strong evidence that even the smallest of gifts or favours can alter their prescribing practices. A study by Dr Ashley Wazana, published in the Journal of the American Medical Association (JAMA), established that gifts, sponsored meals, conference travel, funding for conferences, all significantly alter the prescribing practices of doctors in favour of the sponsoring pharmaceutical or medical device industry.
A 2013 study by Marrisse King in the British Medical Journal (BMJ) found that students graduating from US medical schools that had strong conflict of interest policies against gifts from industry, had a 55-75% reduced chance of prescribing more expensive medication compared to cheaper medication that was equally good. Similar studies may not have been done in India, but they prove the point (unless Indian doctors would like to claim they are more honest/ honourable/ morally incorruptible than their counterparts in the rest of the world).
A conflict of interest is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest. Primary interest refers to the principal goals of the profession, such as health of patients and integrity of research. Secondary interest includes not only financial gain but also such motives as the desire for professional advancement and the wish to do favours for family and friends.
Gifts, travel grants, “cut-practice” are absolutely illegal for doctors according to the Medical Council of India (MCI) rule book. MCI also states: “The personal financial interests of a physician should not conflict with the medical interests of patients.”
There is a reason why the medical profession has always been held up to higher ethical standards than any other. The 2009 Manual of Ethics of the World Medical Association states, “People come to physicians for help with their most pressing needs – relief from pain and suffering and restoration of health and well-being. They allow physicians to see, touch and manipulate every part of their bodies, even the most intimate. They do this because they trust their physicians to act in their best interests.” A doctor has to have way more empathy and understanding than in any other profession. This expectation is neither recent, nor restricted to any particular country.
Unfortunately enforcement by MCI has been very poor, leading to entrenched corruption in healthcare delivery systems in India. Rather than strengthening controls on these corrupt practices, MCI amended its code of ethics to allow institutions and associations to be exempt from the rules on gifts, grants and funds from pharmaceutical and device industries.
The law allows seven or more people to form a society or foundation. So, if you are not allowed to take what constitutes a pure and simple bribe from industry as an individual doctor, you shall be allowed to do so as a group of seven or more! We are already seeing a rapid rise in the number of “societies”, “foundations” and “associations” among doctors to make use of this loophole, as this amendment has been in the works since 2010. This will have disastrous consequences for an already corrupt healthcare system and you, as a patient, will pay for it.
The parliamentary standing committee on health observed that exempting professional associations of doctors from the ambit of ethics regulations is nothing short of legitimising such associations indulging in unethical and corrupt practices. It added, “It seems that the MCI has become captive to private commercial interests.”
Even today a majority of medical practitioners uphold true values and ethics. Unfortunately, their voices and ideas have been drowned by a more vociferous group who believe that success is determined by profit margins, or rather profiteering by healthcare delivery organisations, rather than by high quality ethical care. And yet, they puzzle over rising violence against doctors across the country.
They don’t seem to see that the violence is a direct fallout of the erosion of the trust that doctors take decisions in the patient’s interest and of a sense of helplessness. The US and India report the highest number of attacks on doctors by patients (physical violence in India and “litigational violence” in the US). It is no coincidence that both are countries where healthcare delivery is dominated by a profit-driven private sector.
As doctors we need to be aware of these facts and put public pressure to ensure that the government acts on the recommendations of the parliamentary committee to strengthen the code of ethics for doctors by bringing healthcare institutions, foundations, societies and associations under its ambit. MCI will also have to ensure better and stricter implementation so that justice is seen to be done in cases where the code is flouted. Else, Indians’ health will suffer even more than at present.
DISCLAIMER : Views expressed above are the author's own.