A survey in the United States in the 1970’s and another
survey in India in the 1990’s showed that the general public of both
countries held judges to be the most honest and the most highly respected
among all professionals. Doctors came second in their estimation in both
the surveys. All other professionals ranked lower than the judges and the
doctors.
However it has been the misfortune of all of us that
quite recently we have witnessed a very undesirable trend when the
medical profession is no longer held by non-medical public in the very
high esteem in which it was held earlier.
Members of the public often accuse the doctors of
charging very high fees for professional services. A doctor, especially a
specialist has to study at least ten years after leaving school to get
his undergraduate and postgraduate degrees. He has to work under very
difficult conditions for another five to ten years before he can get a
decent income. This is true whether he is in service or in private
practice. By this time he is 35 to 40 years old and has only another 20
years of active earning before him, to bring up his children and to save
money for his own retired life.
One of our main problems is that the vast majority of
us in the medical profession cannot communicate effectively. We are
unable to convince the public, the media and the government that our
stand is correct. Very often most of us are apathetic and do not try to
convince them either. So we are accused unjustly of unethical standards
in charging fees.
One of the biggest myths perpetrated by many
politicians, many government officers, some of the other professionals
and even by the media is that all the doctors earn a very large amount of
money and good deal of it by unjustified means. It is perhaps possible to
devote an entire oration to explode this myth.
I have been in neurosurgical practice in this country
during the past 40 years. I will confine myself to pointing out briefly
how the cost of medical treatment and income of doctors has risen only by
5 to 15 times compared to the cost of living which has risen 40 to 100
times in different areas during the same period.
The real income of doctors has fallen to one fourth of
the previous level during the past four decades.
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Consultation fees of a
senior specialist
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Charges for a major
operation
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EEG
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X ray skull
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One sovereign of gold
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Ten liters of petrol
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1000 sq.ft flat
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Subscription to a standard
Neurosurgery journal
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Airfare from Chennai to
Trichy
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1964
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2003
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Increased by
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Rs:30
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Rs:400
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13 times
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Rs:1,500
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Rs:20,000
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13 times
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Rs:100
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Rs:600
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6 times
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Rs:20
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Rs:120
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6 times
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Rs: 130
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Rs: 4,600
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36 times
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Rs: 8
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Rs: 360
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45 times
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Rs: 20, 000
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Rs: 20, 00, 000
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100 times
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Rs: 350
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Rs: 14,000
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40 times
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Rs: 90
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Rs: 3, 600
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40 times
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Putting it
differently a doctor with 40 years experience has to work at least 3 to 4
times harder and much longer hours at the end of his career to maintain
the same standard of living he had at the beginning of his career. In
fact he has to work even more as he has to support not only his wife but
also his children and parents towards the latter part of his career.
The Hippocratic
oath states " Whatsoever in the course of practice I see or hear
that ought never to be published I will not divulge but will consider
such things to be holy secrets".
Every profession
has dilemmas regarding confidentiality. Very delicate situations can
arise regarding confidentiality and disclosure between doctor and patient
(in cases of malignancy diagnosis), between priest and penitent (in cases
of adultery and AIDS) between lawyer and client (in cases of suspected
robbery), between banker and customer (in cases of suspected cheating)
and between minister and secretary (in cases of compromising the safety
of the people).
Disclosure of
confidential information is sometimes necessary when there is risk to the
patient himself like suicide or accident, when there is risk of infection
to others like spouses or classmates or when there is risk of danger to
others like passengers or co- workers.
In the famous
case of Tarasoff versus the Regents of the University of California, the
patient told his psychotherapist of his intention to kill a girl. The
psychotherapist did not convey the warning to the concerned persons. The
patient did in fact subsequently murder the girl. The psychotherapist’s
defense that to inform the victim would be against his duty of
confidentiality to the patient was rejected by the court. The protective
function of the privilege of confidentiality ends when public peril
begins.
The Supreme
Court of Canada held in 1980 that “Even if a certain risk is a mere
possibility which need not be disclosed, yet if its occurrence carries
serious consequences, for example paralysis or even death, it should be
regarded as a material risk requiring disclosure”.
Even if the
chance of a complication is very low it may be considered quite
significant in special cases
a. Possibility of 1% risk to recurrent
laryngeal nerve in anterior cervical decompression in a professional
singer.
b. Possibility of 1% risk of blindness
in the only seeing eye in a patient with suprasellar tumor.
c. Possibility of 1% risk of drop foot
in a lumbar disc excision in a dancer.
d. Possibility of 0.1% risk to life if
the patient is the only child of a mother who has been permanently
sterilized.
CONFIDENTIALITY:
If the
husband had azoospermia, would you inform the wife?
If the
husband had gonorrhoea, would you inform the wife?
If the
husband had HIV, would you inform the wife?
If a nurse’s
error contributed to death, would you inform the relatives?
If an
equipment failure contributed to death, would you inform the relatives?
If a
consultant’s misjudgment contributed to death, would you inform the
relatives?
If an unwed
girl aged fifteen is found to be pregnant, would you inform the mother?
If an unwed
girl aged twenty is found to be pregnant, would you inform the mother?
If a married
lady whose husband is abroad is found to be pregnant, would you inform
the husband?
Informing the
patient and relatives of the correct diagnosis and dismal prognosis in
cases of incurable illness -
Arguments for
(If the truth is not told):
1. Patient may
go “ doctor shopping” till he gets the correct diagnosis and in that
process undergo repeated painful, costly and sometimes risky
investigations.
2. Patient may
suffer needless fear and anxiety that his prognosis is even worse than it
actually is.
3. Patient may lose his trust in the
physician when he finds out the truth. He may mistrust all statements and
advice from the physician in future.
4. Patient is
deprived of the opportunity to plan his remaining future life- treatment,
employment, children's career and marriage, will, financial plans,
charities, religious rites etc. etc.
Arguments
against:
(1) All hope
would be extinguished in the patient’s mind. He may go into extreme
depression.
(2) Even
otherwise it is an enormous psychological burden for most patients.
(3) Physician
can never be hundred percent certain of diagnosis. So his information may
be false.
(4) Progress of
the same illness may vary widely from patient to patient.
(5) If patient
does not wish to know the truth, why thrust it on him?
(6) If patient
cannot really understand the full implication, why force the diagnosis on
him?
When a patient
has a malignant glioma of the brain and the spouse, parents or children
ask me” Doctor is it cancer? How long will he live?” I have a simple
method of answering. I tell them, what I have learnt from my teacher
Professor Norman Dott.
“
If there are hundred patients with this type of tumor five of them may
die soon after operation. Sixty of them may not survive more than
eighteen months. However twenty of them are likely to survive up to three
years. And the last five may even survive more than five years. Who knows
in which category your patient is going to be? Let us hope he will in the
last category: but let us also be prepared in case he falls into the
first category”.
When
you put it like that, you have given them the exact truth, you have
warned them the patient may die soon after or within a few weeks of
surgery but at the same time you have given them hope that the patient
may in the lucky 5% who survive five years. The human brain always
believes that there is a high probability of getting the one in thousand
chance of lottery prize but does not believe there is reasonable
probability of getting the one in ten chance of a road traffic accident
while driving above the speed limit.
A
fully conscious educated employed young lady refuses all food and drinks.
Her husband has just deserted her. She is highly depressed but is
otherwise quite normal. Her health has deteriorated to such a state that
unless urgent measures are taken to prevent starvation and dehydration,
her life may be in danger.
Can
the family doctor admit her in a hospital against her wishes? Can she be
sedated without her consent and given feeds by Rye’s tube, intravenous
fluids and antidepressants? If only a distant relative, close friend or
employer gives consent, can the doctor be protected in a later legal
action against him? Is it enough if he takes a second opinion from
another doctor, supporting his decision? Is he preventing attempted
suicide or is he infringing on basic human rights? Should he obtain a
court order to support his decision?
A
young man who is underweight and is a known diabetic develops acute
appendicitis. The surgeon suspects that the inflamed appendix may rupture
any time and cause peritonitis. He advises emergency surgery to prevent
this. In the meantime the patient has the relevant medical literature scanned
on the Internet and requests that only antibiotics should be given. He
refuses to undergo operative treatment.
The
surgeon feels that for this particular patient conservative treatment is
highly risky. The surgeon feels that surgery has to be done within an
hour or two to save life and there is no time to transfer him to another
hospital. The parents agree with the surgeon. The patient is adamant in
his opinion.
Can
the surgeon take the father’s consent and sedate and operate on the
patient against his wish? Should the surgeon take an informed refusal
from the patient and give only antibiotics? Should the surgeon refuse to
treat the patient saying he does not agree with the proposed conservative
line of management?
Mr.
Quackenbush was a chronically ill elderly diabetic. He developed gangrene
of both legs. The attending surgeons advised amputation in both lower
limbs. The patient refused surgery. He felt he was going to die soon
anyway and would rather die whole than live a little longer without his
legs.
The
surgeons tried to have him declared incompetent because of his
“irrational” decision. The psychiatrist found that Mr. Quackenbush
clearly understood his choices and their implications. The case was
referred to a court.
The
court held that the patient’s decision was rational under the
circumstances and that the surgeons should not override the patient’s
decision.
A
sixty year old doctor is admitted with a history of sudden onset of right
hemiparesis and dysphasia a few hours earlier. At the time of admission
Glasgow coma scale score is 4 / 15. CT scan shows a large left hemisphere
infarct. Within two days he loses all brain stem reflexes, which can be
clinically elicited. He is on a ventilator but his blood pressure
is maintained without ionotropic support. His wife and daughter want all
supportive measures to be continued and if needed ionotropic support and
cardiac resuscitation. His two sons want all supportive measures to be
withdrawn. Whose directions should the doctor carry out?
Some
very difficult situations can arise when the doctor has to decide when to
withhold treatment or withdraw treatment already started. These may be
multiple congenital malformations, Incidentally found slow growing
tumours, advanced malignancies, practically brain dead patients and post
tumor excision situations.
A girl
aged one year with a lipomyelomeningocele in the lumbo-sacral region is
brought with total paraplegia and double in-continence. She has hydrocephalus
and an Arnold Chiari malformation. She is a precious baby
born after ten years of married life of very rich parents. The baby’s
mental milestones are normal.
Should
we operate on this child ? Can we ever make her walk? Because
the parents can afford any expense , can we do multiple operations? How
much money can we make the parents spend? Not only money but time,
energy and other resources of which the family is in great need. Is it
ethical to operate ? Is it ethical to refuse to operate?
It is
very easy to say that parents have to give the informed consent or
refusal when you provide them with all the facts. Are parents always
capable of taking such a decision? It can be very difficult because of
1. Their young age,
lack of education, poor knowledge and immaturity.
2. Their emotional
situation – the shock of facing the crisis. They expected the perfect
child but the new arrival is not only imperfect but permanently disabled.
3. The short duration
of time available in which they have to take the decision. The parents
have little time to digest the totally unfamiliar medical information
showered upon them in the intensely emotionally charged atmosphere of the
pediatric intensive care unit when they are suddenly told that the child
will be paraplegic and incontinent, that an emergency operation has to be
done within a day or two, that this operation will not cure the existing
disabilities of paraplegia and incontinence and that the child may also
develop a hydrocephalus or other problems in future requiring a second or
even a third operation.
Freeman
said, in 1973 “It is imperative however that if one embarks on therapy it
should be vigorous therapy”. And what does vigorous therapy involve?
Excision of
myelomeningocele
Shunting for
hydrocephalus
Periodical
neurological, radiological and psychological assessment
Re-operation if
needed for tethered cord
Another
operation if needed for syringomyelia, Arnold-Chiari etc.,
Revision shunt
when needed
Orthopedic care and operations
Plastic surgery in some cases
Urological care and operations
Treatment of associated medical problems
Physiotherapy
Continuous careful medical care throughout life
Counseling of patient, parents and family
Education of the family physician
Education of the child
Training for employment
Placement in suitable employment.
Closure
of the back is the first step
Unless
all the other subsequent steps are carried out successfully, the overall
result is equally bad or sometime even worse than that of the untreated
child.
If we are not treating the child
surgically and waiting for the child to die and ‘nature to take its
course’ –
where do we draw the line in medical
treatment
Should we treat
meningitis when it occurs? How far do we go?
Should we treat
chest infection if it occurs? How far do we go?
Should we treat
urinary infection when it occurs? How far do we go?
Should we treat
renal decompensation when it occurs? How far do we go?
Would you accept the following from
pharmaceutical, surgical, equipment manufacturing and other firms:
Letter pads
with company’s address',Drug samples,
Pens, clocks,
household items, suitcases, bags, X-ray lobby, BP apparatus, Medical
books, Journals,
Non medical
books, journals
Money for
breakfast / lunches for departmental lectures, clinical meetings
Travel tickets and hotel expenses for
conferences, CME programmes
Money for Awards for Best Paper in conferences
Money for Conference Support – sponsoring
sessions, souvenir advertisements,
Sponsoring lunches / dinners.
Is not the cost of all the above passed
on indirectly to the patient making health care more expensive for him?
Adapted from
Guidelines issued by the American Medical Association Council on Ethical
and Judicial Affairs (1991)
and by the
American College of Physicians (1990).
Acceptable
Gifts
that benefit patients (eg) text books, drug samples
Gifts
of minimal value used by physician in his work (eg) notepads, pens
Subsidies
for independently planned and controlled educational meetings
Not Acceptable
Gifts of substantial value that do not benefit patients (eg) travel
ticket
Gifts
with ‘strings attached’
Gifts
that might influence objectivity of clinical judgment.
Gifts and other
amenities provided to doctors at meetings especially when they do not
directly benefit patients or cannot be used in the doctor’s professional
work (eg) alcoholic drinks, art objects as momentos.
Would you charge
professional fees for any of the following?
1.
Practicing
Doctor
2.
Qualified Doctor – now businessman
3.
Medical
Student
4.
Dental
Student
5.
Qualified
Nurse
6.
Nursing Student
7.
Qualified Physiotherapist
8.
Physiotherapy Student
9.
Businessman
whose son is a Doctor and accompanying patient
10. Businessman who is a NRI
doctor
11. Businessman whose father is
a doctor and accompanying patient
12. Businessman whose father is
a doctor in another town.
13. Doctor’s poor servant whose
bill is paid by the doctor.
14. Doctor’s well to do family
priest whose bill is paid by the doctor.
15. Doctor who has medical
insurance.
If a right to
treatment exists, is there a right to demand treatment, which is futile?
Once the physician recognizes a treatment is futile, how should he
proceed? Inform patient / relatives? Wait for them to bring it up?
Stop without consulting them? Continue with informed consent?
Stop with informed refusal?
MEDICAL
FUTILITY
Physiotherapy
Surgery
Antibiotics
Chemotherapy
Cardiac
resuscitation
Intervention A may be futile in a achieving goal X but may not be futile
in achieving goal Y. The aim of medical treatment is not merely to cause
a ‘beneficial’ effect on some portion of the patient’s anatomy,
physiology or biochemistry but to benefit the patient as a whole with
special regard to alleviation of symptoms, quality of life and duration
of life.
If you ask the relative “Do you want us to do everything possible?” he
will of course answer “Certainly yes, doctor”.
If
you tell the relatives that CPR for a cardiac arrest in a severely head
injured hypertensive diabetic decerebrate eighty year old patient who had
been comatose for three weeks on a ventilator has less than a 1 in 1000
chance of making him recover ultimately, but will only prolong his ICU
stay for a few more days, almost all the relatives would say “Please do
not resuscitate, doctor”.
Why
do relatives want futile treatment to continue
1. Ignorance about
true prognosis – inform them correctly with repeated frank discussions.
2. Confusion –
because different specialists attending on the patient give different
opinions.
3. Mistrust – of
the doctors, nurses, hospital
4. Evading
responsibility – due to fear of blame by other family members, or since
someone else is footing the bill.
It has
been our great good fortune in this life to become doctors and enter a
very noble profession. Let all of us stand united and do our utmost so
that the medical profession in our country will truly become the noblest
of all professions and every public opinion poll will list us at the top
even above the judges.
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