Medicine, money, morality

Balasubramanian Ramana*

doi:10.1038/nindia.2016.123 Published online 19 September 2016

Book Review

The Ethical Doctor

Kamal Kumar Mahawar, Harper Collins India (2016) 

ISBN: 9789352640096

Buy this book: India US UK

The book might well have been titled The Ethical Indian Doctor, given that its focus is the Indian medical industry, of which the author was once a part. The likely reason the word is missing, the cynic might muse, is that the author believes there is no such tribe as the Ethical Indian Doctor.

And who, honestly, would blame him? Modern Indian society has exhibited newer depths in morality, and the medical industry has been one of the easy whipping boys.

The author, now a practising medical doctor in the UK, comes across as a friend and a good human being: someone you would be relieved to have on your side during a tough medical crisis, and be equally at ease arguing about sundry things over a single malt. 

Mahawar knows what he is talking about. He is not manufacturing stories or sensationalising stuff. He cares about the malaise affecting Indian medicine enough to clinically expose all the skeletons in the outhouse wall. He traces the ills of modern medical care to Hippocrates, and questions the validity of the Medical Council of India’s rambling codes of behavior for doctors.

It is now universal — this condemnation of the commercialisation of care, the unnecessary testing and billing, and the fleecing of the vulnerable patient. One thing though — this is not merely an Indian disease. The American system is a rich example of corruption. Perhaps it is better dressed, in a bespoke suit. The naked greed and ‘running the system’ are reasons for the Indian system's dysfunctionality and teetering on breakpoint.

Mahawar, while being accurate about the impact of unethical commercial and state-run medical practice, errs in its diagnosis. He picks the low-hanging fruit in blaming unbridled capitalism. He identifies greed and the profit-making motive amongst Indians as causes of rampant malpractice and escalating treatment costs. This explanation may not suffice to the more discerning. On the contrary, it seems that state-controlled education has fostered a culture of amorality to corruption (it is ubiquitous, and you get used to it, like bad odour), and participation in it. The private sector, holding profit as its religion, is innovative in ‘running the system’. The mere policing of the industry would be counter-productive, as “who will police the police themselves?”

In the modern era, the free market of information is finding ways of identifying reliable and honest, high quality doctors and hospitals. Yes, they do exist, but one may not even know about them. Free patient fora, doctor-rating websites and outcome-based insurance compensation to doctors are some of the ways the market is responding to the medical industry exploiting the gullible public. 

In a world where the most visible hospitals and doctors are often quietly over-billing patients to pay for their massive PR budgets, perhaps it is time to openly acknowledge that medical care is a paid service, a commodity. Patients must know that they are consumers seeking help from a professional, who will earn by providing quality care and advice. Honest money should be the root of an open patient-doctor relationship. A cardiologist paying commission to receive a heart attack case is as guilty of trading on the patient’s sick heart as is a pathologist exploiting your stool by charging for testing a diarrhoea sample. Emotive, but not rational.

In a laissez-faire market, all medical transactions involving money would have specific payouts. Just like a travel agent getting a cut from the hotel and airline, and the Government getting a cut from your income and restaurant bill. With this open system shorn of moral judgment, no one would baulk at paying or taking money for a patient. Because, after all, medicine is business. It just needs to be an ethical one.

Alas, there is no chance of this being even a discussion on social media: the very concept is so disruptive and un-Hippocratic. That said, Mahawar has done a splendid job that deserves wide recognition for its passion, depth, practical honesty and candour. That a book on medical ethics can be so absorbing is creditable.

* The reviewer is President, Asia Pacific, The International Bariatric Club, and a practicing laparoscopic surgeon based in Kolkata, India.