By Dr. George Jacob
Kochi, Feb 10, 2020: Healthcare dispensation does not function on a one plus one equals two formula. It is a product of churning of ethics governing the profession and dilemmas faced by its dispensers.
Doctors come across numerous occasions where they are required to treat patients in whom treatment is futile. Occasions where precious money is wasted on lost cause. These include brain-dead patients, and those with advanced cancer. Brain dead patients need to be resuscitated and stabilized, if their families consent for organ donation, so that good-quality organs are made available to recipients. Treatment of such patients ceases once organs are harvested.
Patients diagnosed with advanced cancers who deserve to spend their last days with their families must only be offered palliative care in cheaper and basic health facilities than in prohibitively expensive ICUs. This has to be legally formalized into law.
However, situations are aplenty where families of such patients demand continuation of futile high-end treatment despite being advised against and briefed about the futility of treating them. Reasons for such requests are social: to await arrival of a dear and near beside the dying, or to satisfy the family’s conscience that ‘everything possible was done for the patient’, or because the family needs the patient to remain alive and conscious as long as possible in instances of conflicts over inheritance of the patient’s worldly possessions.
Here, doctors are forced to comply with the family’s request to ‘go all out’, albeit reluctantly. Futile Treatment continues while hospital bills swell. Bad blood is spilt between doctors reluctantly treating such patients and families who arm-twist them to do so. Physical and verbal skirmishes ensue within hospitals between treating personnel and confused and embittered families of patients being treated unnecessarily.
At the other extreme, patients with apparently ‘benign’ diseases like pancreatitis, and vascular pathology of bowel, sepsis or even ‘flu’ seek treatment. These patients are unique in that(1) complications during treatment, and the diseases’ natural history itself could be drawn-out and financially demanding, and (2) should they survive the long- drawn treatment, go on to survive their entire lifespan with reasonable quality.
Logically, treating such patients is worth it. But, any disease, however seemingly ‘benign’ or ‘commonplace’ can run into well-described complications, inflicting unaffordable financial burden on patients and their families. Even common flu, also called H1N1 is known to go through serious life threatening complications like ARDS, necessitating many days on the ventilator, and expensive treatment modalities like ECMO, dialysis, and prohibitively expensive antibiotics as Kerala witnessed in the first half of 2018.
Treating so-called ‘simple diseases’ which run into complications entails huge financial burden on patients unexpectedly. This poses an ethical dilemma. It is the duty of doctors to treat these patients, giving it their best shot. Patients treated for so-called ‘benign diseases’ require prohibitively expensive treatment, with infection, primary or secondary, playing the villain, necessitating costly surgical interventions and frequent investigations.
It is here that noble and well-meant intentions of doctors to ‘get such patients well somehow’ are misconstrued by patients’ families as ‘medical professionals of trying to make big money by employing ‘ costly treatment unnecessarily’. These patients form a unique subgroup, where to treat them by going ‘all-out’ is worthwhile on one hand, but is prohibitively expensive, with hospital bills mounting to humongous amounts, on the other. How many in India can afford this?
Medical personnel involved in treating this subgroup of patients ‘are caught between the devil and the deep sea’, in today’s healthcare scenario. It is the question of raising big money to treat these patients, by no means easy that form the crux of a great dilemma.
Ethical questions such as: ‘How far should these patients be treated?’ ought to be considered, considering the huge costs involved. But, won’t that amount to prematurely withdrawing treatment to patients who stand a high chance of survival? This dilemma and ethical issues need to be deciphered in the interest of the health of Indian healthcare dispensation.
India lacks a comprehensive policy on euthanasia. It is high time Indian judiciary laid down clear-cut legal policy and guidelines on euthanasia. Euthanasia must be considered in patients with advanced malignancies, brain-dead patients unwilling to donate organs, and in patients leading a vegetative existence, dependant on costly equipment and drugs to sustain life in vain.
Patients being treated for ‘benign’ diseases linger in ICUs receiving prohibitively expensive treatment, as fighting for them, with no holds barred is worth it. It is in these situations that doctors must be helped by well-prescribed regulations and laws, as to ‘how far treatment must be offered’, as chances of survival are real. It is when huge amounts of money are spent by patients’ families, and treatment gets prolonged, that bad blood is shed on the doctor-patient family relationship. These are situations which ultimately result in physical attack on hospitals and treating personnel, sullying medical profession.
Lack of Consistent and honest communication and briefing of patients’ families by doctors add to the former’s suspicion about the latter as bills swell daily. Charges of ‘doctors spending money for nothing’, and ‘doctors pulling fast ones about patients’ chances of leading a quality life after survival’ fly thick and thin.
This issue has to be settled comprehensively by the collective effort of the government, the MCI, or its new version, and people’s representatives through NGOs, and the judiciary. This delicate and sensitive issue is not taught in medical colleges, nor are they included in the medical curriculum. Medical students must be made aware of this stark reality, which they’ll be called to face aplenty after graduation.
Often, families of seriously ill patients refuse to see the writing on the wall. They refuse and are not in a frame of mind to accept lack of patients’ improvement, their worsening, or worse, death. Social workers, psychologists and counselors have a lot to do in this delicate situation.
Instances where healthcare facilities have been ransacked and treating personnel manhandled and physically attacked by irate family of patients, who die or fail to improve, are rampant. The press, during such instances find pleasure in adding fuel to the fire by reporting incidents of ‘medical negligence’, on many instances unsubstantiated, and churned out of rumor mills. This causes a great disservice to medical profession.
India lacks a credible insurance policy or state support for its sick, in line with the West, where citizens are covered by medical insurance. The Indian government needs to ensure that citizens have something to fall back on, in times of medical crisis, especially during emergencies.
The budget for the years 2018-2019 had proposed health insurance cover of Rs. 5 lakhs/year for secondary and tertiary care hospitalization for 100 million poor families. This gave a flicker of hope to the sick and the healers. But, such well-meant attempts continue to remain on paper.
Similarly, the Kerala government had also proposed to pay for initial treatment in emergencies, where the money will be later claimed from insurance companies. It remains to be seen how far the country’s insurance companies would cooperate with these path-breaking populist measures. These winds of change infuse hope into healthcare dispensation in the country, which has clearly taken on dangerous portends for the personnel involved by way of threat to life and property, and mental anguish suffered.
The other glaring cause for the unfortunate turn for the worse healthcare in India has taken is overdependence of doctors and treating personnel on costly gadgets and investigations. Costly Invasive monitoring systems have rapidly replaced cheaper noninvasive ones, especially in the corporate tertiary care hospitals, which can afford to have them.
Despite the so-called ‘giant advances’ in medicine, nothing, till date has replaced dedicated bedside practice of medicine, where patients are treated by doctors and nurses who station themselves beside sickbeds. This unfortunate turn for the worse starts from the hallowed halls of medical schools in the private sector.
The words of legendary physician William Osler (1849-1919) ‘medicine is learnt by the bedside and not in the classroom. Let not your perceptions of disease come from words heard in the lecture room, or read from the book. See and then reason and compare and control. But, see first’, have been forgotten to be relegated to medical history books. There is an increasing trend among fresh medical graduates to rely on costly gadgets, machinery and investigations (sometimes repeated ad nauseum), citing ease of diagnosis and treatment.
While this might be true, bedside medicine cannot be replaced by flashy gadgets. Absolutely cheap and basic simple steps of clinical medicine viz: inspection, palpation and auscultation still hold good, and serve well to diagnose diseases even today. Bodies like The MCI must reinforce basics in medical curriculum and education.
Finally, the most vicious curse to have befallen medicine in India is the mushrooming of ‘medical colleges’ in private sector. Entrusting private players with medical education is akin to arming a bank looter with an AK-47! Gross commercialization of medical education has come to stay as the worst bane to have robbed medical education in India of credibility, standards and nobility.
Admission to such ‘medical colleges’ created out of wayside kiosks are available in the ‘market’ at exorbitant rates running to lakhs and even crores for super specialty courses. Some of these medical colleges even lack patients, to be clinically examined and diagnosed by medical students, again tearing into pieces words of William Osler, who famously quoted; ‘he who studies medicine without textbooks sails an unchartered sea, but he who studies medicines without patients, do not go to sea at all.’
Students who have absolutely no aptitude and attitude to take up responsibilities of doctors, graduate by hook or by crook. Their sole intention as doctors is to somehow reclaim huge money spent by their parents for their medical ‘education’. They represent ‘dream come true’ of their filthy-rich parents, and to satisfy their rich parents’ ‘social standing’ by having their wards graduate as doctors.
Merit has been shown the backdoor by this pitiable state of affairs in medical education, as it is, in today’s India. Admission to medical courses ought to be solely on the basis of merit measured through credible entrance exams and nothing else. Big money and private money-spinners who have seen convenient ‘geese that lay golden eggs’ by setting up medical, nursing and dental colleges ought to be checked in the interest of the health of medical education that, currently attracts suspicion, loss of credibility and malicious intentions by Medical Boards worldwide.
Is there treatment for these maladies?
‘Treatment’ there is, if those concerned like the government, judiciary and MCI are ready to apply balm, mend broken bones, and remove cancers that have come to infiltrate the ‘art of healing’ in India, lest that art becomes a curse for India, and her citizens, as it is now.
• The place to begin would be public hospitals. Facilities existing in these hospitals must be escalated at least to basic levels where thousands with simple diseases form long queues seeking their services. High-end investigation facilities can wait till public hospitals are equipped with simple things like cotton, dressing materials and simple medicines like Paracetamol. Results of simple blood tests must be issued without delay to help in treatment. More patient beds are called for in the wards, as many patients are found to languish on the floors of the wards seeking treatment. The government must be willing to spend more to spruce up health care, even at the cost of other money-intensive national priorities like defense. Before equipping public hospitals, especially teaching ones with high-end gadgets and machines for investigations, stress should be made to equip operating theatres, emergency departments and outpatient departments with more facilities, especially basic ones.
• Doctors in India must master the delicate art of communicating patient’s response to treatment, even if it is bad news of failure to improve, and impending death. Often it is the glaring failure on the part of doctors to communicate honestly, and openheartedly, that is the starting point of breakdown of a positive relationship with the patients’ attendants. No facts, however unfavorable must be kept under wraps.
• Having said this, there is a huge responsibility on doctors to take into confidence the families of patients by briefing them daily honestly, and without hiding facts about progress or deterioration of patients being treated.
• This sensitive issue of patient-doctor, and patients’ family-doctor relationship and it’s nurturing must be inculcated into medical curriculum, and even be included in qualifying examinations
• The government must spare no effort to put in place a comprehensive medical insurance for every Indian. This will undoubtedly entail an extremely huge amount of money considering the nation’s population. The medical insurance must be based on a premium, though menial, paid by citizens. The insurance must cover substantial part of the bills incurred during hospitalization, most importantly, in emergencies. These days patients sadly chose to walk away from hospitals, unable to cough up money when emergencies strike out of the blue. This must stop. Another important aspect of governmental support to the country’s sick is reimbursement of medical bills accrued by government servants. Though such facilities exist now, the snaillike pace and red-tapism involved makes it as good as nonexistent. This facility must be expedited.
• The country, by collective brains of the government, judiciary, MCI and NGOs must put in place clear-cut policy and guidelines on euthanasia. The practice of treating patients who will not respond to treatment, and for whom treatment is futile and even unethical must be stopped. Money must not be allowed to be wasted on lost causes. Such patients’ families must not be allowed to plunge head-on into penury.
• As important as a framework on euthanasia. Legal guidelines must be laid down in situations where treatment of so-called benign diseases, especially when treatment tends to be long-drawn process due to complications that often set in. How far should doctors go about treating such patients? Should a ceiling on money that needs to be spent to cure patients be laid down? Should treatment of such diseases be limited to a particular limit monetarily? Such difficult ethical questions must be addressed. It is time they are. Should Doctors be allowed to play God when the patients’ families are being decimated beyond redemption financially? When they are being bled by rising medical bills?
• Runaway billing practices so rampant among hospitals in the corporate sector must be strictly regulated. A close scrutiny of bills reveal numerous ‘hidden’ categories viz; ‘miscellaneous’, nursing charges, rounds fees, medication charges that add up cruelly to the bills rolling out of billing machines in private hospitals making them money-spinning behemoths, than revered centers of healing. The government must put in place strict billing patterns by private hospitals that they cease to arm-twist the poor sick Indian.
• Medical education in India must be uncompromisingly made out of bounds for private players. Admission into medical, dental and nursing courses must be based on merit measured by tenable entrance examinations and nothing else. When legislators themselves run medical, dental and nursing ‘colleges’, one cannot see this happening!
• Involvement of good Samaritans, well-meaning individuals, corporate houses and clubs which are socially conscious and who nurture humanitarian causes must be encouraged to shoulder at least a part, if not the entire expense incurred, especially by the poor, who seek medical treatment in India as charity. After all there is nothing wrong for the haves to help the have-nots, as there is nothing wrong for the government to cut defense expenditure, and to siphon money thus saved to bolster dispensation of medical treatment in India, so that medical treatment ceases to be a curse to Indians within India.