“It's the love of right (that) lures men to wrong.”
― Kim Stanley Robinson, Red Mars
Should I be ethical or moral? That is not a question that you may have considered often in your life. You may ask, “Isn’t being ethical means being moral too?” Well, read on. I am going to narrate five incidents, the likes of which we face very often. Each incident raises a question. All these five questions were posed to me by my young friends. They thought that I would know better, because of my advanced age and years of experience. But my advice landed some of them in enormous vexation. So, I am turning to you better answers.
Miss or tell?
A. Ashish, a young resident in Chandigarh was called to the emergency department to attend to a young adolescent girl with acute liver failure. Her poor father had carried the girl in his lap for over 100 km on a bus. He had borrowed money from the village Sarpanch to travel. It was his a last ditch effort to save his daughter’s life. Ashish soon realised that the girl carried a very poor prognosis (80% chance of dying within a week). She could survive only with liver transplantation. It was obvious that this poor man did not have the money to afford that treatment.
Ashish hesitated as he was unable to decide. One option was that he should tell her father that a treatment was available, but was beyond his financial reach! The other option was that he should keep quiet and not talk about liver transplantation with him (and feel the guilt of not being truthful with his patient’s family). Does morality lie in hurting a person by harsh truth or in keeping quiet?1
He finally decided to do what his ethics dictated. He told the father about the available treatment. Her father looked at him for a few minutes and said, “I thought I did more than I could for my daughter before I came here. I would have accepted her death as God’s will. But now, thanks to you, I have to live my life with the guilt of having failed to save my dying daughter.
Later the resident wrote, “This father had come to my hospital with the burden of a sick child, and only little hope. When he returned home he had to find a way to live with a profound sense of loss and guilt.”2
Adding life or years?
B. A 62 years old father of a corporate CEO (Ms Bhavna) developed jaundice due pancreatic cancer in Delhi. Despite yellow colouring of the eyes and some loss of appetite, he was relatively asymptomatic. He had no pain or itching. Dr. Bhoomi, the oncologist, investigated him and found that it was stage IV cancer with metastasis in the liver. She discussed various options with the family and suggested palliative biliary stenting followed by chemotherapy, which could increase median survival from 6.8 months to 11.1 months.3 Bhavna had said, “Please do whatever is best for my father!”
As a complication of the stenting procedure he developed pancreatitis, which took four weeks to settle. Once jaundice came down and he recovered a bit, chemotherapy sessions were started. This led to more adverse effects. He lived for almost two years in total after diagnosis. Dr. Bhoomi was very happy with the outcome.
However, Ms Bhavna (patient’s daughter) felt otherwise. She knew her father was asymptomatic when he came for treatment initially. All his symptoms were related to side effects of the treatment. In the two years that he lived, he had seventeen hospitalisations with symptoms related to various procedures, and chemotherapy. The cost of around 34 lakhs for total treatment did not mean much to her, but seeing her father suffer for 2 years disturbed her no end. She now wished that some doctor could have advised her to let him fade away without treatment. She accusingly said, “No doctor warned me about the magnitude of suffering the treatment would cause. Maybe he would have lived less than a year without treatment but chances were that he would have been more comfortable and at peace with his family at home.” Dr. Bhoomi was feeling let down asked me what should she do in the next such case?
Toe or go!
C. Chandravardhan, chief medical officer (CMO) of a district HQ in U.P. was struggling to cope with the spurt of cases involving a mosquito borne viral encephalitis infection (JEV) a few years back. One day, the chief executive officer (CEO) of the area called him to his office. The CEO told him that the spurt in JEV cases was causing panic among public and tarnishing the image of the district. He should report lesser numbers – lesser than the average of surrounding districts. Chandravardhan was an honest doctor and expressed inability to falsify records. The CEO had even suggested that the CMO may lose his job unless the latter showed declining JEV numbers. On my advice, he continued to be truthful and reported the numbers as they actually were.
Two day later, after some angry words, CMO was suspended for inefficiency in carrying out Government health programs. And his deputy was promoted as CMO. The deputy decided to toe the official line and reduced the numbers being reported from the district immediately, justifying the action of the CEO! My friend is cursing me for the advice given.
Say or pay!
D. Dharmistha, a 39 years old lady in Andhra Pradesh, a mother of 3 children, was brought to casualty with severe cholangitis and septic shock. Her children (14 and 12 years old girls and a 11 years old boy) brought her to hospital in a cycle rickshaw. Father of the children, a labourer had gone to Mumbai to work. The nearby Government hospital was closed due to a large number of COVID-19 cases.
Patient was provided IV fluids and antibiotics. Her condition indicated that she was unlikely to survive without an endoscopic procedure – stone extraction/stenting. Her children did not have the money to pay for it. The procedure was also not covered in Government schemes announced for persons below the poverty line. Dr. Deepak, who saw the case, initially talked to the Director of Medical Service (DMS) for permission to do the procedure as an emergency and waive off the cost. The DMS refused and said, “Only i.v. fluids and one shot of antibiotics in emergency. If you do anything more, you will be billed for the same.” Dr Deepak asked my opinion,”What should I do?” If he performs the procedure to save a life, the consumables will be debited from his pay. If he does do it once, what is the guarantee, that every other day, a case like this will not turn up?
Fudge or budge!
E. Dr. Eeshwer was a retired professor of pathology. He had taken up a job in a private hospital in his home district in Gujarat, because his family was in dire need for money. He was also in-charge of a molecular biology lab that was doing COVID-19 RT-PCR tests. His work load recently had increased, but he did his best to cope with it.
One day, a high Government official visited this private hospital including its laboratory. The visiting dignitary was happy to see the lab and commended his work too. But after the visiting official went back, the CEO of the hospital called Dr. Eeshwer to his office and said,”The visiting dignitary has told me that nearly all our tests are being reported positive for COVID-19. He has directed that the positivity rate should be brought down to around 50%, otherwise there will be a panic in the city.”
Dr Eeshwer was aghast. He had done his job truthfully and did not know what to do now. There was a hint that he might lose his job if he failed to do as directed? If he lost his job, how would he fulfill his family’s requirement? Could he change the threshold for positivity without thinking about its implications?
Poor man’s medicine is poor medicine!
Cases A and D are clearly linked to poverty which apparently is the biggest cause of adverse outcomes in any disease. Socioeconomic status is the most powerful predictor of disease, disorder, injury and mortality we have.4 We know that, ultimately, impoverished children with a chronic disease or cancer diagnosis face higher rates of morbidity and mortality than others.5,6,7
Our healthcare system fails to provide full protection against such improvishment. Not only that, the rising out-of-pocket expenditure (met with by individual citizens) needed for medical care pushes more than 55 million Indians below the poverty line every year.8 Our constitution provides for ‘right to health’ indirectly though article-21, 9 but that is on paper only. Ayshman Bharat scheme is an attempt in the right direction but there are too many loop-holes remaining to be plugged.
Government hospitals can provide free care, but they are overburdened and have inadequate facilities. One reason is the low level of spending by the government on running the health infrastructure—only 1% of the GDP, which is among the lowest in the world.10 Consequently, the out-of-pocket expenditure as a proportion of the total health expenditure is as high as 65%.11
Finally it is the doctor who becomes the last man standing in front of the patient/family telling them something that no one wants to hear. Ethically he is bound to say, “Yes, a treatment is available and the hospital has the capability to save your life!” But can he convert his words into action? In a private hospital, he will be chucked out in no time if he provides free treatment. It is his moral duty to his employer to tell the patient that ‘treatment comes at a cost. Come to me if you have the money.’ A daily dilemma that leads to physician burnouts12,13and stress that may even give him his premature heart attack! Some people have described this phenomenon as ‘moral injury.'14
Balance autonomy and beneficience
Case B is a problem of counselling. When pretreatment counselling sessions are done, patients are generally optimistic. A person with money and power comes to the doctor to purchase health. Sometimes he is ignorant about the real situation and remains in denial for a long time. Doctor’s ability to accurately predict outcomes is limited.15
So he gives them statistics derived from the population studies. Even if the physician describes the possible adverse effects of treatment, the patient and family do not fully comprehend the possible suffering as they have never suffered before. Many patients will leave the decision to the physician as Ms. Bhavna did. The latter situation is tougher on the physician. The family will always blame the physician later if anything untoward happens. Distraught call from Dr Bhoomi is an example. Even though ethically the physician is right, he/she still has to take the moral responsibility of the patient’s suffering. Once all the options have been placed on the table, it may be better to allow the patients to choose the course of action and exercise their right of autonomy.16
On the other hand, too much reliance on autonomy and giving it preference over beneficence, as is encouraged in certain private institutions is another cause of ‘moral distress’ among doctors.17,18
Boss is always right!
Cases C and E are similar, though the levels of action are different. One is in the public sector and the second in private sector. JEV and Covid-19 are public health emergencies that reflect on the executive’s administrative efficiency. But in every organisation, executives have immense power over doctors that treat the patients. Very often a doctor finds himself at the receiving end of the executive’s misplaced(?) perceptions or intentions. Examples here are the executive’s desire to under report the disease incidence. His overt explanation is that higher incidence may lead to a loss of morale in the lay public. Covertly, he may be trying to save his own skin. An executive in power will often act on his perceptions and apprehensions.Let us not discuss whether his decision is right or wrong. We do not know how much of it is due to his genuine concern for the public and how much due to a desire to project that he is effectively handling the situation. JEV and Covid-19 are just examples. Enormous amount of pressures are also brought upon doctors working with non-governmental organisations, who are reporting ground level health indices from rural areas.
When such an executive causally asks the doctor to fudge the records, he clearly does not wish to understand its real implications. It also signifies that he is not willing to place his own conduct under scrutiny by his superiors. So he asks his lower ‘insignificant’ officers (or those who are under his/her power) to do the dirty work. What do you do if you have an immoral boss? Here it is the doctor who has been left to struggle with his ethical duties of being truthful about his medical findings. The physician has to weight his ethical duty to profession against his moral duty to his employer (What if executive’s perception is right?). And mostly the doctor would pay for his stubbornness by losing the job and his reputation. Often a redressal in court is also not possible as such orders are always given verbally. And the person waiting in fringes to replace the doctor, is unlikely to stand for him. If such orders are asked in writing, it is considered impertinence and insubordination. The outcome would be the same.
I had raised an issue of “Watchdog with a Bone” in my blog in early June this year.19 I wonder if there was a mechanism similar to this one playing behind those issues at a higher level?
Drop dead righteousness
It is easy to say, “Clinicians have strong fiduciary duties to patients, meaning that they have the duty to place the interest of the patient above almost all other competing concerns.”20 Medical ethics has always asked doctors to put their patients first, even at some risk to themselves. Physicians are often asked to care for patients with infectious diseases, even at risk of their own health. It was done in some quarters during COVID-19 pandemic when PPE was in short supply (read not available). To uphold their ethical obligations, doctors have been advised even to disobey or break the law in certain circumstances.21 To stand by this ethical norm, is it imperative for a physician to destroy one’s own life and career? Or for that matter patient’s or family’s sense of satisfaction (as in Ashish’s case)?
A Swedish study accepted that such moral distress is common place in medical and nursing practice and suggested that organisations should strive to reduce it.22Another study also gives numerous examples of similar conflicts in setting of corporate influence on public health.23 What does a physician do when faced with such conflicts in his/her daily life?
I have changed the names of the person’s involved and in many cases their location. You will notice that the names start with A, B, C, D, and E. The incidents are real though. And they raise some questions that deserve serious considerations.
What would you have done in these situations? I look forward to your views.
References
| ↑1 | Pietikäinen, P. (2004). Truth hurts: the sociobiology debate, moral reading and the idea of “dangerous knowledge.” Social Epistemology, 18(2-3), 165–179. doi:10.1080/0269172042000249273 |
| ↑2 | Rathi S. Rules and rues. Lancet. 2016;388(10040):122-123. doi:10.1016/s0140-6736(16)31028-5 |
| ↑3 | Conroy T, Desseigne F, Ychou M, et al. FOLFIRINOX versus gemcitabine for metastatic PC. N Engl J Med 2011;364:1817–25. |
| ↑4 | Mukherjee K.Poverty as a cause and consequence of Ill health. International Journal of Epidemiologic Research, 2015; 2(4): 209-220. |
| ↑5 | https://www.ucsf.edu/news/2016/01/401251/poor-health-when-poverty-becomes-disease |
| ↑6 | https://blogs.worldbank.org/opendata/disease-preventable-cause-poverty |
| ↑7 | ”The Relationship Between Poverty & Infectious Disease.” Study.com, 25 January 2017, study.com/academy/lesson/the-relationship-between-poverty-infectious-disease.html |
| ↑8 | https://thelogicalindian.com/story-feed/awareness/medical-debt-pushed-million-indians-poverty/?infinitescroll=1 |
| ↑9 | Anand, AC. Indian healthcare at crossroads: Quo Vadis? Natl Med J India 2019; 32(3): 175-180. |
| ↑10 | The World Bank. Domestic general government health expenditure (% of GDP). Available at https://data.worldbank.org/indicator/SH.XPD.GHED.GD.ZS |
| ↑11 | The World Bank. Out-of-pocket expenditure (% of current health expenditure). Available at https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS |
| ↑12 | Panagioti M, Geraghty K, Johnson J, et al. Association between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-analysis. JAMA Intern Med 2018;178(10):1317–1330. doi:https://doi.org/10.1001/jamainternmed.2018.3713 |
| ↑13 | Shanafelt TD, West CP, Sinsky C, et al. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017. Mayo Clin Proc 2019;1–14. doi:https://doi.org/10.1016/j.mayocp.2018.10.023 |
| ↑14 | Talbot S, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT.https://www.statnews.com/2018/07/26/physiciansnot-burning-out-they-are-suffering-moral-injury/. |
| ↑15 | ”https://roastedamygdala.com/2020/08/que-sera-sera/” |
| ↑16 | Dzeng E, Wachter RM. Ethics in Conflict: Moral Distress as a Root Cause of Burnout. J Gen Intern Med. 2020;35(2):409-411. doi:10.1007/s11606-019-05505-6 |
| ↑17 | Dzeng E, Colaianni A, Roland M, et al. Influence of Institutional Culture and Policies on Do-Not-Resuscitate Decision Making at the End of Life. JAMA Intern Med 2015;175(5):812–819. doi:https://doi.org/10.1001/jamainternmed.2015.0295 |
| ↑18 | RI Hilliard, C Harrison, S Madden. Ethical conflicts and moral distress experienced by paediatric residents during their training. Paediatr Child Health 2007;12(1):29-35. |
| ↑19 | https://roastedamygdala.com/2020/06/watchdog-with-a-bone/ |
| ↑20 | Presidential Commission for the Study of Ethical Issues, “Anticipate and Communicate,” testimony of Alex London, p. 60, December 2013, at http://bioethics.gov/node/3169. |
| ↑21 | Davis DS, Kodish E. Laws that conflict with the ethics of medicine: What Should Doctors Do?. Hastings Cent Rep. 2014;44(6):11-14. doi:10.1002/hast.382 |
| ↑22 | Kälvemark S, Höglund AT, Hansson MG, Westerholm P, Arnetz B. Living with conflicts-ethical dilemmas and moral distress in the health care system. Soc Sci Med. 2004;58(6):1075-1084. doi:10.1016/s0277-9536(03)00279-x |
| ↑23 | Baur X, Budnik LT, Ruff K, Egilman DS, Lemen RA, Soskolne CL. Ethics, morality, and conflicting interests: how questionable professional integrity in some scientists supports global corporate influence in public health. Int J Occup Environ Health. 2015;21(2):172-175. doi:10.1179/2049396714Y.0000000103 |
All very dicy situation, the outcome is unperdicable if you do otherwise. Always Doctor will be blamed.
Very thought provocative article written very nicely
dear sir.
this paper can be written only after years of clinical experience. the clarity in thought, passion for patient care, empathy and judgement required on dealing with day to day cases faced are evident in every single case you have mentioned in this paper. Very many thanks for sharing this. regards
Dear Sir,
You continue to explore facets of practicing Medicine in your inimitable style that seldom gets discussed. These dilemmas are often extremely difficult to handle and there are no easy “correct” answers.
The first step to seek answers is to confront the existence of these questions and this article does the job perfectly.
A must read article for all of us.
Dr Anand
It was nice to see such an article in Indian context today which has sincerity and compassion written large in complete text. The vivid mention of the burden of knowledge and the same on your conscience while dealing with such situations with our patients’ clearly demarcates you and puts you on a pedestal of different stature; of a physician who has lived life on principles of service to humanity with complete faith and dedication. Well written.
Excellent Brain Teasing scenario. My view being moral at times better than to be ethical for a bigger gain to society. Lord Krishna was also advising on similar lines to Arjun
What would you say to Davies?
(Davis DS, Kodish E. Laws that conflict with the ethics of medicine: What Should Doctors Do?. Hastings Cent Rep. 2014;44(6):11-14. doi:10.1002/hast.382)
This Sunday reading of the piece “Should I be …” has all the elements to nurture. Maj Gen Dr Anand brings to us such cogency to real life.
Our medical and nursing profession in India,with so many different and disjointed levels of health care delivery requires our daily balance between morality and ethics.The changing societal norms demand higher inclusion of -Teaching and training on topics/modules on Narrative Medicine,Ethics and Communication in all courses.
Medicine will always remain the best bond in society out of all human transactions.
Thought provoking article
Reminds me of the old adage often attributed to the late Henry Kissinger “Nothing in this world is black or white ; everything is a shade of Grey”
Apart from the four pillars of ethics which in current circumstances are very shaky ; veracity is demoted to a more insignificant position
Clinical decision making is an art and science with practitioners vacillating between both
The art part of it involves ethics and adjustability ; the science evidence knowledge and skill
Unfortunately to understand the best balance in a given patient in a given situation is a challenge that might defeat the most astute clinician
Medical colleges teach mainly science. The art comes later, sometimes after paying hefty price.
Sir, you have beautifully penned down the ethical dilemmas in clinical practice. About oncology cases I think it is a reality and treating the patient fetches money to the treating doctor. This fact mostly prohibits him from telling the truth about quality of life with treatment. If health care is nationalized, and salary is not linked or insentivised as per numbers treated doctors in India will start explaining the other side. Ofcourse nationalization has failed in ost countries due to various reasons.
Morality and fudging reports to better statistics, such issues everyone will act according to his or her capacity to withstand adversities.
Thanks for bringing up these real life issues on this platform
[8/29, 9:21 PM] Yojana Gokhale: Aruna Ghogale, yes for Tocilizumab
[8/29, 9:23 PM] Yojana Gokhale: Mohinidevi Sharma yes for Tocilizumab quality of life
Is that Tocilizumab for COVID-19???
Post retirement from Air Force I did geriatric practice for 8years. Amongst the cases were a number of maignancies of patients 70years and older. After getting the provisional diagnosis, confirming diagnosis and treatment options many of them got back with a query doctor if this was your father/mother what would you do. In some cases I said with the prognosis I would not put them through further suffering if this was my parent. However I have tried to explain the pros and cons to you. Since it is your parent/relative I cannot decide for you
Dear sir , an untold story of most of us brought out so perfectly apt examples . It is so nice to see you talking about such many issues and gives a bell to the ears . In my opinion , there is an overlap in the two words and most often the ethics and morality go hand in hand .
In case A , ethics and morality dictate that you do the best and tell the truth . Life has never been fair in that sense . In the end what matters is you have done your best ,both as a doctor and as the father .
I think similarly in other situations too
But certainly ,this is a common dillema that all of us face ,surely more for out profession but other professions are not averse to it wg IAS
warm Regards Atul
I always thought that the greatest luxury a Doctor can have is to be able to completely treat any patient he/she sees irrespective of financial comfort or otherwise… possible in certain specialities ..the turmoil of deferring treatment because of lack of finances is probably the most stressful everyday situation for a sensitive doctor.. Excellent exposition of the social burden apart from scientific stress on a physician presented in an interest generating pattern..Kudos
Dear Dr. Anand,
The eternal dilemma of our profession neatly put in words. Each professional plays her/ his cards on a – “contextual and personal ability to handle fallout “-framework. The consequences and agony of guilt, shame, frustration and so on are the personal hurt suffered thru life. It is the unrecognized burden carried on behalf of humanity. Training to face such situations, focus on preventive measures and a peer group that shares the burden could be the possible remedies.
Very thought provoking article!
In our day to day practice almost every other day we come across such situations!
As a medical personnel, one must also learn the art of communicating the facts and evidence appropriately depending on the situation! Of course, we will not and cannot judge the patient’s background accurately all the time- therefore, when not sure err towards being moral than being ethical!
Hitherto, we had the luxury of deciding on the behalf of the patient- but this is no longer considered appropriate!
Ultimately, do no harm, or if not possible, cause least harm if you can not do or be good!
fantastic article. do you have sources for any further reading on medical ethics, sir?
I googled for you and found a list of journals on ethics (https://en.wikipedia.org/wiki/List_of_ethics_journals) and a list of ethics courses (https://www.coursera.org/courses?query=ethics). Even Harvard university runs courses on ethics online. (https://online-learning.harvard.edu/subject/ethics)
Excellent depiction of the difficult to decide scenario. Very very thought provoking
I think A doctor should do all what is in his power to treat patient (power not capability).
About fudging documents, If your high morals don’t allow you to do so, go out and gain more power and place to change it as you are literate. Your priorities are different then dont think about it just do your job michenically.
About asymptomatic stage 4 cancer pt, As per my opinion a person deserves a better life rather than long life. A docotor should give best suggestions as per his experience, after conveying all possibilities. I know its possible as I have seen my self some of this patient.
Thought provoking situations……All of the situations pose moral/ethical questions and its difficult to find scientific answers for them… but the fact is that we do answer them daily with our actions……Its high time these philosophical questions are discussed more openly so that justice is done to the maximum possible extent….
Sir,brilliant as usual.
Sharing.
Most of us would have gone through such clinical dilemmas at some point of time…
These remind me of the Vikram and Betal stories which in the end has 2 options … Do it .. you are dammed .
Don’t do it … still you are damned ..,
Adding to the complexities you now have the distrust of the patient and the Medico legal sword hanging on your head .
I wonder what Krishna would have advised if Arjuna was in such situation.
Dear Sir, Thanks for the article. Very real scenarios. Ethics has two major streams_ Rule based Ethics and Greatest Good or Consequence based ethics. Medical ethics with few notable exceptions like an infectious diease or violent mental disorder is Rule based where individual autonomy is paramount. The public and private setor problems are classic Duty to Obey issues. But you have shown the dilemma nicely. Same as Arjunas dilemma. Do or dont do. Which is right. Ethics would advice not to go agaist your conscience. In the first two problems I feel telling the whole story with all decision points and consequenses is the only ethical way. Discussed proprely with empathy it is possible to make the father understand the ruinous path of transolant and the rich man the reality of ‘treatment’ in advanced cancer. Good doctors achieve this everyday. Medical ethicals is necssarily rule based_ imperstives to maintain uniformity of conduct. But consequences need to be eeaved in deftly by the physician. Thiis is why philosophy schools in the west are veering towards Virtue ethics _ promoted by the ancient Greek _ Aristotle, Indian and Chinese civilisations. Good Action is what a Good person would do. It puts the focus building moral character of the agent_ the doctor here_ annd aeay from blindly following rules or making calculation of consequence. This frees the virtuous person to act based on what he or she thinks is best – which is not a throwback to paternalusm. The best action comes out of your good character. If this sounds vague then remember it puts the moral ball firmly in the court of the agent_ doctor. There is no rule to hide behind. The word used to describe Dharma in the Mahabharata is sukshma – subtle. Its not an easy road.
A firm clear response sufficiently backed up by history and philosophy.Moral relativism cripples.Responsibility with all its consequences is not a world of half-measures.The patient is all -morally or professionally.Valorising a profession thru moral quibbling is feel-good sophistry-fit for bars or drawing rooms.To get on with it is the ethical and professional battle.
Well said. But can one tear away from the fabric of the society one lives in?
I understand the situations and dilemma of decision making. I always thought as a physician I have taken a oath to abide by the medical ethics and accept the consequences. Morality is a particular system of values and principles of conduct especially one held by a specific person or society. It is individual choice .
Dr Anand
For the first time in india some one has written thought provoking. We as Indians whether educated or uneducated give less importance to health. Infact we know prevention is better than cure. Many diseases can be prevented if we provide clean water and food to every individual. Many in india think hospitals are temple and doctor is god, hence they expect good outcome. Also no one in family talks about death. I hope practicing medicine in India, is different which we should have subject to learn soft skills during MBBS.
Situation will improve only if government hospitals have all infrastructure. They should start with good PHC in all district, to avoid overcrowding superspeciality. If they invest on PHC and secondary center for 8 to 16 PHC, it can take care of 80% of problem. Most of poor people either have infection or injury.
Whatever you said is true’.
Thanks. The study of soft skills is being inducted in MBBS course. Primary and secondary centres exist on ground. But health care funding is dismal.
Five instances commonalities and contexts! It is almost like Roshomon! Is ethics or morals is the horns of the dilemma! For doctors ethics is professional code without which they cannot function and there is morals about what is right and wrong. The limits of ethics or boundaries of dilemma within which morals can way are truly individual choices! However for the cases for where the boss wants you to be compliant, there is no choice with both ethics as professional code of Medicine applies as well as the moral of right or wrong! Often such a choice implies shutting of one door and opening of another! Very wonderfully narrated and placed for our study Sir!
I agree. Though some times, even if rarely, boss may want you to comply genuinely for larger good!
Read it through. A thoughtful piece asking questions that beset us every day.
Morality and ethics are not at loggerheads – they both arise from the same sense of right and wrong.
What the case scenarios indicate is that ethics are not principles which we can apply like a formula. There’s are always tensions between the 4 principles, all of them grounded in what we collectively think of as right. When money is the question, that too is a part of beneficence and non malfeasance that need to be integrated. Autonomy doesn’t stand alone to be taken into account without the other 3.
The corruption in the system is the challenge to our moral conscience. This is the daily existential question ( as to our moral being) everyday.
A good account of ethical dilemmas provided. I think most of the dilemmas have origin in conflict between personal interests and larger patient interests. Much depends upon how much we are wedded to truth. Truth is always Singular. A doctor to my knowledge will not starve. Hence no need to abide by concept of Boss is right. Transparency of a professional in his dealings helps building trust. This forms basis for excellent doctor patient relationship. If a doctor feels he is answerable to his consciousness, he may not have any difficulty in tackling individual cases. He must be conscious in all his dealings. Not compulsive. Transparency and accountability should not make him a bad healer. Healing should start in the minds of patient. Where affordable constraint is there, it may not be prudent to suggest costly options. For every option suggested, implications should be thoroughly discussed. It is better to quit the organisation, where he can’t exercise his professional autonomy in an ethical, conscious manner. Much depends upon individual’s value system.
Cant agree with you more. Thanks.
Dear Sir,
Very important issues have been highlighted by you in your elegant style. I Shall try to honestly answer to your appeal of what the reader would do.
Case A where the patient cannot afford treatment. Options available be told. The patient may have a source. Many act poor too. I will also explain the negatives of the transplant operation and life thereafter so as to reduce the emotional burden on the father. I will also tell that medical treatment today can be so expensive that it cannot be afforded by even 1 in a lakh individuals. Everyone has a limit. Money cannot buy health and immortality.
Case B. I will ask the patient to decide and not the next of kin. The consent be taken from the patient. I shall not treat without the patients informed consent.
Case C. I will not falsify statistics as it has far reaching implications on epidemiology based actions to combat the disease.
Case D. I have a budget allocated from personal funds for charity. Help those whom you can knowing that I cannot help all.
Case E. I will not do false negative reporting of COVID 19. This will result in spread of disease, financial loss and deaths in geometric proportions.
Agree with you in all cases.
A. There is a mortality and infection risk in transplant and post- transplant immunosuppressive therapy- in this situation should not be presented as a magic bullet- may help mitigate the father’s grief.
B. When Ms Bhavna said to do whatever’s best for her father, the doctor should have had a conversation with her father about his goals and expectations. I suppose at any point the patient could have refused further care if it was too burdensome. Unfortunately palliative care medicine and hospice services are nonexistent in a lot of places.
D. This is putting the doctor in a really untenable position. The poor doctor has to bear the burden of the collapse of the system. Even if he pays for the ERCP what of the ICU stay to follow?
You have a very clear mind. Many don’t. But I am sure you too are troubled at times!
Dear Dr Anand,
Thought provoking and insightful article. Conflict between ethics and morals is the most difficult to resolve. Whether one should stand by ethics imposed by external agencies or his morals is a universal dilemma. Thanks for the wonderful article
Dear Anil,
YOU always write thought provoking articles in a different way to keep the readers’interest intact throughout. It was an interesting piece to read and think about the dilemmas faced by us during the course of our interactions with our patients as well as their relatives. Being an anaesthetist and always closely associated with surgeons, often I had to face such catch 22 Situations and we had to decide between moral and ethics depending upon which used to haunt in our minds for quite a time . Sometimes our known persons as well as relatives too ask for advice and it is very difficult to advise one way or the other.
Enjoyed your article throughly, request to add me in your mail for future blogs/,articles.
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Dear Gen Anand,
Congratulations for putting the issues so explicitly and so dispassionately .
All the 5 case scenarios, true as they are, are day to day experience of all of us. Conflict of ethicality and morality in situations of data fudging is not difficult to decide . There is always the danger of loosing your job if you are working under an ambitious unethical superior. If one toe to the line, will it make it better for the doctor? So why compromise?
Autonomy over beneficence is a much more sensitive issue and our comation skills play a very crucial role in preventing the emotional physical and financial issues afterwards.
Standing up to financial support by the treating doctor if the situation so demands is not something a doctor should find himself morally bound to and therefore I would not be affected morally as I have experienced in my four and half decades of intensive care practic.
A lot depend on how genuinely we practice our profession or for that matter vocation. Thank you once again for this magnificent thought and depiction.
In the first case after immediate emergency treatment and hospitalisation the young doctor could have sat with the patients and explained the modalities of treatment and explained ti the father that had he himself been dealing with his own family member in such circumstances he couldn’t have afforded the highly expensive modality of treatment
I’ve done this myself many times and seen the burden of guilt reduced many times
This also could have helped Ms Bhavana take appropriate decision of allowing her father’s disease take it’s natural course
Case D is most unfortunate and makes one feel as helpless as the relatives
Cases C & E are very commonly seen and need governmental sensitivity and responsibility in proper place – A tall order indeed
Can not agree more
Regards
Agree with Dr Jos V S opinion
Dear sir,
The doctor in this blog was trapped in a dilemma as he made morality and ethics as two watertight compartments and he thought he could be either moral or ethical.. In fact Morality is distinguishing good from bad, while Ethics is the science of Morality., it lays down the standards by which to judge morality. This science is shaped by societal thinking and at times by judiciary. For example Gay sex was considered immoral but now with amendment of article 377 of IPC it is considered acceptable or if i may add ethical. Ethicists limit the use of word “ Ethics” in the practice of a profession, while others use it interchangeably with Morality. If the Society/Judiciary lays down rules of conduct with patients then the doctor should flow with those rules .. In the clash of ideologies , while the doctor thinks on spread of disease, the administration adds the economic, social impact of the disease before making a decision. What better example than the COVID 19 pandemic. Would you call this decision of administration unethical? So there are no wrong or rights it is all a matter of perception.
Well said
A. The poor man must know the reality that Liver transplant is expensive and is unaffordable to vast sections of the society. Hopefully it will motivate him eventually to join the long term war against dietary habits leading to liver diseases such as alcohol and contribute to a progressive society after the initial guilt trip is over.
B. Money cannot buy everything. This kind of suffering teaches ppl this valuable lesson. Can it be avoided.. No, Medicinr is work in progress. Pts who can afford terminal care contribute to betterment of science & to a better tomorrow for others. Progress in medicine is not just a one way street involving doctors, Human suffering has preceded every invention in medicine.
C. Reporting lesser numbers by the ground level staff is falsely is not going to help or rectify the ground situation. It will only worsen it. If your deputy is willing to do it, let him face the music and watch the fun. Eventually when the situation becomes too hot, the public wint have enough beds and will show their wrath. Which is better, being in the line of fire or in the sidelines watching the situation unravel.
D. This situation is best addressed by having a corpus fund in the hospital with contributions from a grp of rich donors who have benefitted from your care as your pts. Everytime you get a pt who needs help, sound out this grp with pitiful images of the pt, and videos requesting help. Someone is likely to respond. If no one responds, it means the programme is not being run successfully. We recognize honour such contributions annually at a function where citations r given, local media publicity is ensured, and social recognition of the philanthropy is acheived.
E. Post retirement, if this job doesn’t give you what you want, you should be able to leave it and take up another job. Its your failure if you still require this job that asks you to report lesser covid positivity.
Very good suggestions
A firm clear response sufficiently backed up by history and philosophy.Moral relativism cripples.Responsibility with all its consequences is not a world of half-measures.The patient is all -morally or professionally.Valorising a profession thru moral quibbling is feel-good sophistry-fit for bars or drawing rooms.To get on with it is the ethical and professional battle.
A firmThe doctor – author writes lucidly on certain interesting experiences borne out of his own experience.They are truthful but raises uncomfortable questions on the challenges consequent thereupon. My own only observation would be that the worthy doctor has brought upon himself through the anecdotes cited an avoidable confusion on morality and ethics.To my simple understanding these two are generally used interchangeably and do not stand in opposition to each other.Perhaps it could have been simplified by replacing morality wherever used with being professional.I am conscious of the term “professional” has pejorative connotations which in this instant cases maybe also be substituted with the word”realism”.His epigrammatic opening quote is clearer in this regard I’d imagine.
If I might add my two-anna bit, I would say – what is after all the right Dharma is a conundrum.And that seems to have carried on, not without reason,I must admit,since Arjuna laid down his weapons in despair on the bloody fields of Kurukshetra and it took a Bhagwadgita to be compiled and document the famous sermons of a Krishna to explain away the problematic.
That said the jury is still out on that. clear response sufficiently backed up by history and philosophy.Moral relativism cripples.Responsibility with all its consequences is not a world of half-measures.The patient is all -morally or professionally.Valorising a profession thru moral quibbling is feel-good sophistry-fit for bars or drawing rooms.To get on with it is the ethical and professional battle.
Well, ethics and morality are not same. My understanding is that (a) ‘Ethic’ denotes an extrinsic set of rule made by society for a group of individuals to guide their behaviour. (e.g. medical ethics for doctors); while ‘Morals’ come from one’s own internal compass about right or wrong. (b) Ethics is explicit (clearly laid down), while morals are implicit and often come from one’s upbringing (or sanskar). (c) Ethics is a map of how one should make choices. Morality is an unwritten code that can be used to judge behaviour and will vary from time to time and may be from culture to culture.
Of course, we can agree to disagree on this.
As we make technological progress , conflicts will continue . For the cases presented by the author, my two cents.
A.For the child as of today -Keto / Milaan is an option. @Dr Ravi Joshi Ped Oncologist, can vouch for this
Previously also there were crowd funding opportunities but not as organised as today.
B. Wisdom is retrospective in nature ! There are patients who have done well in such scenarios and give hope to doctors and patients alike! If the outcome was unifactorial and linear , counselling would be easy. Even when we explain the side effects , it is not that all patients have side effects in the same fashion. If no treatment was taken at all and few miserable months were only available, one would still express regret.
C. The CMO if he is cursing the advice , his ethics / morals were wrong in the first place. He should be proud that he did the right thing. Losing the job would not be the end of life for him. We all have a choice and he made a choice. To be happy with the choices we make, we need the right peers.
D. Use a code where the government will reimburse and do the procedure .
E. If the family requirements has to compel him to take a wrong decision, it is a sad state of affairs. The needs can easily be met but not greed. The moral duty to his employer cannot be at conflict to doing the right thing. Perception being right is a false argument compared to the data at hand .
I think trying to place the decision making on external agents is a way to avoid the conflict which we face because of incentives driven behavior.
We need to acknowledge that incentives do influence us in how we place the options in front of our patients, relatives, colleagues and other stakeholders
Thanks for your comments.
I could not understand Keto / Milaan for acute liver failure.
Your suggestion to ‘Use a code where the government will reimburse and do the procedure’ may amount to being unethical as well as immoral in a sense, apart from being illegal!
Keto/Milaan are crowdfunding platforms which raise amount for patients predominantly pediatric.
Agree with you Sir that the option of using a different code could be illegal! One cannot probably do a right by so called doing wrong !
Dear Anil, thanks for a very thought-provoking blog. We have all faced such dilemas at various times in our carreers. The basic principle I follow is that ethics override every other consideration, if one wants to sleep with a clear conscience; yet I will not fault someone to does toe the line – I do not know his/her compulsions
In cases like A, i always counsel the relatives that they should never feel guilty for their decisions; they have done the best that they could at that point in time.
Cases like B – in elderly patients I feel quality of life overrides quantity and that is my advice to my patients, but I let them choose. A procedural complication cannot be anticipated; if the complication had not occurred, he would have had a better QOL. The side effects of chemo are known to all and so the relatives should not blame the doctor once they have decided on chemo.
I had a patient like case D who had an acute limb ischaemia following myocardial infarction and was advised AK amputation in a different hospital. The patient could not affort treatment in a private hospsital; when seen by me I fel the limb could be salvaged and the vascular surgeon agreed with me. The question was the cost – spoke with the hospital management and the did give some discoount; the surgeon, anaesthetist and I did not charge any professional fees and thrombectomy was done and the limb saved. Maybe we cannot do it for everyone one, but even once case like this justifies one’s existence!
Finally, re C and E, as I said, I feel ethics are important. If one has been long enough in an organization and has establishes his/her credentials, there is no way the powers-that-be could fire him/her. This will happen if the person is junior – in which case he should tell the boss to ask his HOD to do the needful.
Regards,
KS Rao
Thank you sir for your very clear thoughts. I can not agree with you more.
I couldn’t have said it any better. It furthers my point – there is always a right way. The blog post is a whimsical exercise in self glory. Sadly
Zindegi Ki kusmakus me hum Sub bandhe huaie hain. A well meaning doctors life is not easy neither zindagi ke sare raste aur risten. But one thing I have experience d that source of funding greatly influence the decision making. Emotional reading. A great outing in pandemic days. Thanks Admiral Anand.
My take might be simplistic- but say the truth all the time- it liberates you. What if the father in the first case comes to you and says “ if only you told me about the liver transplant, I would have arranged the money somehow “. Whose cross is it then to bear ? Being upfront about options / costs/ outcomes etc is very important. It is unfortunate that doctors have to advise on the financial implications of medical decisions.
Regarding the ercp case – do it- as it is life saving. And then you have time to mobilize the commentary from the hospital. If you don’t do the ercp- the patient could die. Do you want the burden of that cross ?
To me , this diatribe is an exercise is how morally bankrupt we have become.
There is always a right way, however grey the world might be.
Thanks. Spoken from the heart. I agree.
Thought provoking yet again, Anand. Gratifying to note that instead joining the band wagon who sweep such inconvenient situations under the carpet you have chosen to ask “What can be CORRECT decision”.
I see three issues here: Ethics, Morals and Hindrance from administration (Boss, as you call it). Running through all three is perception of patients & public. Medical profession and patients face this mortifying spectacle of affordability is because only 25% of health care is in public sector while 75% rests with profit oriented public sector.
I submit that Ethics and Morals are not mutually exclusive. What is ethical has to be moral & vice versa. This is applicable to ALL walks of life as well as interpersonal relationship. “Ethics is defined as a moral philosophy or a code of Morals practiced by a person or a group of people”.
Now to the issues raised by your illustrative cases: Bottom line, as far as I am concerned, is my duty to the patient. If adherence to such principle may harm the physician, I will accept it. Two reasons: Truth will prevail. Second in the long run you will be considered “Reliable”. Ashish should have told the father “ Your daughter is critically ill. And then added a half truth “Even with the BEST medical care available in planet earth survival cannot be guaranteed”. If a direct question is asked “Money is the problem?” Ashish should answer “ Yes, but we are looking at the accepted outcome “. This kind of reply may indeed reduce the burden of guilt in the father. Yes, what was said was only half truth but your primary duty to the patient and her father is well served. This will remain valid till one can guarantee 100% success with liver transplantation in “ACUTE LIVER CELL FAILURE”. Lord Krishna persuaded Yudhishtra to convey to Dhronacharya news of death of elephant named “Aswathaama”. Every Indian knows the rest.
Case of MS Bhawna’s father is common in today’s multispecialty hospitals. Here what is deficient is proper communication. Bhawna should have been told, in private, about dire prognosis in advanced CA Pancreas. Surgery is not a viable option. Before chemotherapy is given level of jaundice has to be brought down. Therapeutic ERCP can achieve this. But again this procedure is not without risks, starting from failure to cannulate, sepsis and so on. Chemotherpy has its own unwelcome adverse effects. Bhawna should be told to discuss with family members and decide. If after understanding the problems involved family gives the green signal the clinician can proceed. By revealing to Bhawna all the problems clinician cannot be dubbed “Prophet of doom”. One wants an INFORMED consent from next of kin. All can be happy if result is good. Otherwise this was a deliberate effort and none need to be aggrieved. “Primum non nocere” is the oath you and I are sworn to.
Dr.Chandravardhan’s predicament seems inescapable as long as ‘Administrator’ controls the doctor. It is up to the doctor with self-pride owing allegiance to principles of medical practice not to be cowed down in matters purely professional. Yes, fear of reprimands, posting out, even losing the job are all real. One who has, after a herculean struggle, gained the four alphabets MBBS cannot starve while the administrator, if thrown out, will find himself in the streets. Of course, due respect should be given to the administrator remembering that there is a Lakshman Rekha here also.
Dr.Deepak & patient Dharmishta: Problem here is neither medical nor administrative. It is socio-political. SEVEN decades had passed by and health care delivery system at governmental level remains pathetic providing fertile ground for PRIVATE medical services a fertile field to plough at will & reap a rich harvest. Doctors will remain impotent spectators till public awareness rises demanding health care as a fundamental right.
Thank you sir. Poor healthcare system remains a big void in a lay citizen’s life and a source of stress for providers.
Dear Sir,
It is always a pleasure to read your blogs. The sentiments expressed in this blog are very relevant to day to day medical practice. The dilemma to be moral or ethical confounds us all. I feel we shouldn’t forget social conditions and patient status whenever we face such a situation. It may be legal to be ethical but one should remember social compulsions of the patient’s family before we decide to embark on the ethically right journey. Even Lord Krishna recommends methods which aren’t very ethical in Bhagwat Gita.
I would like to comment particularly on the Chemotherapy patient cited in your blog. I am personally of the opinion that Oncologists (all sub-specialities included) tend to over stretch themselves and treat many cancers that are essentially untreatable at present. They paint a relatively rosy picture of the therapy and do not effectively highlight the cruel side-effects of surgery, chemotherapy and radiotherapy. The poor patient is desperately looking for a chance to survive and is ready to plunge into spending his/her life-saving on therapy (many of which are not well established). The relatives spends huge sums of money to somehow make their kin survive. What the physicians fail to drive home is the fact that they are only prolonging life and death is imminent. They also fail to drive the fact that therapy will limit their functionality severely, especially in those who are already very emaciated.
I have seen many patients die early because of ill-advised intervention by over-zealous physicians. There are many illnesses which still remain on the incurable list. We should refrain from trying to offer radical therapy for them and rather restrict ourselves to palliative therapy.
As far as the other cases described are concerned, corruption and self-propogation of government officials drives them to misuse their power. It is my view that it is better to get terminated from your job rather than be false.
I don’t think there is any dilemma in any of these stories – all of them are straight-forward. As far as the poor patient is concerned, we should put ourselves in their shoes and tell them frankly what we think after a cost/benefit and risk/benefit analysis. The hospital itself should develop revised gold standards based on the patient’s capacity and local resources. The rich patient with cancer should have been given counsel from both the medical and quality of life point of view, many new expensive protocols are ‘superior’ to old ones but if we look at them carefully, 5 year survival increases by 3 months or 6 months for an aggressive protocol with a lot of side effects (even if money was not a problem). There are a number of patient support groups which give stories that patients can look through on their own before they take a good personal decision. If the condition is terminal, it is better to invest in high quality palliative care instead of compromising residual quality of life for the sake of a few extra months. The Covid and JE stories are simple – we can’t tell lies, if there are consequences to not telling the truth, we have to bear them. The one on poor patient in a corporate hospital – that is the problem with working in a corporate where the objective is to increase investor value – the patient is only a means towards that. A happy corporate doctor is not bothered by that, he gets his salary and treats those who can afford him and his hospital but if the doctor in the story was concerned, he should consider quitting and joining a mission hospital (or other non-profit hospital) instead.
Patient support groups is a wonderful idea, where available.
Unfortunately, mission hospitals in the area may not yet have the facilities to treat.
Very well articulated. Not only in medical profession but in all professions one has come across situations where in the copy book ethics and morality are at loggerheads many a time.
I have always gollowed what my heart says irrespective of the immefiate implication personally on me.In the long run truth is appreciated and prevails
So true,Expressed so explicitly concisely.
Dear Dr Anand
You have correctly highlighted scenarios we face in practice.. As you have highlighted, often these come up because of inability to afford for example the young patient with acute liver failure where the father has to live with the guilt of not being able to afford a liver transplant for his child. It is high time public hospitals start doing transplants and saving lives.. My experience is that now there are many crowd funding agencies which fund transplant, so transplants are becoming a reality for some un-affording patients especially children but there is no support after the transplant which puts the entire onus on the family and he treating doctors. I would choose to mention the option of liver transplant in passing in a situation like this and maybe highlight that it may not always be successful especially in the acute liver failure setting just to reduce the guilt factor for the father.
The other extreme situation of advanced pancreatic cancer has arisen because I feel the family was well affording and hence “everything possible” was tried but with a poor quality of life for the patient and the care givers. Had the patient been non affording, it would have been simpler to give symptomatic treatment and avoid prolonged suffering.
The way I deal with some of these situations is ask myself -“what would I have done, had it been a close family member?” I clearly would not have tried chemotherapy and endoscopic therapy in the patient with advanced pancreatic cancer knowing the overall dismal prognosis with this cancer…