I attended a very interesting conference on Medical Ethics over the weekend where I was invited to give a presentation on the ethical aspects of IVF. My talk was on IVF - the good, the bad and the ugly, and I will be uploading this soon.

What I found very interesting was a talk by one of the organisers, Dr Sunil Pandya. He posed a very provocative question - Are conferences on medical ethics of any use? He was lamenting the fact that inspite of organising many such conferences, the standard of medical ethics seemed to be going progressively downhill in India. Medicine is perceived to be a money making business rather than a profession; and doctors are seen to be greedy individuals, out to maximise their income, rather than act as healers.

Is this a sign of the changing times we are living in? Are we fighting a losing battle? Can we do anything to improve the situation? Can ethics be taught? And are doctors willing to learn?

Most medical students become doctors because they are idealistic. They want to become healers because they like helping patients and want to help them to get better. Unfortunately, medical college seems to kill their ideals and dreams. They often become cynical and uncaring. There are few good role models they can emulate, and in fact they often end up learning bad habits from their seniors – for example, how to be rude to patients so they can complete their duties and find time to catch up on their sleep.

Things are even worse when they start practice. Sadly, no one encourages a young doctor to be ethical. In fact, there is a lot of pressure on the doctor who has just hung out his shingle to be unethical, because the only way a new doctor seems to be able to get patients today is by providing cuts and kickbacks to the referring family physician. Woe betide the junior doctor who does not toe the line – he is likely to be forced to sit in an empty clinic, twiddling his thumbs! Please remember that young doctors just starting practice are very vulnerable. They are under a lot of financial pressure, as they have loans to payback and families to feed, so they find it quite easy to justify these payments to their own conscience. They are easily tempted to take shortcuts - after all, everyone does it – so why shouldn’t I? And I’ll only do it in the beginning – I’ll stop once I am well off. Unfortunately, this is a steep slippery slope and once doctors start going downhill, it’s practically impossible to stop and get off! In order to pay the cuts, they are forced to accept part of their fees in cash, and then the next easy step is to under-report their income and cheat on their taxes.

The presence of pharmaceutical companies with their billion dollar marketing budgets is another potent force in causing doctors to lose their ideals. These companies are easily

able to seduce doctors into prescribing their expensive drugs, even when they are not in the patient’s best interests, and it’s hard to resist the temptation. Diagnostic centers and laboratories which provide a “referral fee” just add to the vicious cycle, which means that it’s becoming easier day by day to count the number of ethical doctors on your fingertips.

No one likes being unethical. I believe that most people are upright, and would rather earn an honest living, so they can sleep well at night. Most doctors who are well off would rather earn a comfortable income ethically, rather than sell their soul for a few extra rupees. If a doctor has an adequate income, most will refuse to be unethical for an additional measly 20%. However, if he stands to lose over 50% of his income by sticking to his high moral principles, then most doctors, like most ordinary citizens, will crumble. It’s not fair to subject doctors’ morals to such an unfair stress test! The present system practically forces young doctors to become unethical!

Unfortunately, self-regulation by the medical profession has failed miserably. Similarly, policing by the government is a very ineffective solution, which actually creates even more unethical behaviour, as doctors learn to game the system.

We need to change the ecosystem in which doctors practice. I feel the major reason for the sad state of affairs today is the presence of middlemen between the doctor and patient. This middleman could be the family physician who refers patients to specialists; or the HMO , who decides which doctors are going to be on their panel. If we can cut out the middleman who demands his cut, and ensure that the doctor-patient relationship becomes a simple and direct one, I think doctors will have much more incentive to remain ethical and practice honestly. Under these conditions, I believe most doctors will prefer to practice ethically !

Is this a pipedream? No ! I’d like to offer a simple practical solution which I feel can help to improve the situation and we are trying out the following experiment, to see if it works. HELP is offering grants to provide free websites for doctors. Millions of patients are already online, looking for good doctors – and we need to ensure that good doctors have an online presence, so it’s easy for patients to find them. We hope these websites will help good doctors to showcase their talent, and will allow them to grow their practice ethically. This will help patients as well, who will become aware of what services ethical doctors provide, and what medical facilities are available in India.

The transparency which the web imposes will: 

1. help to reduce costs, by promoting competition;
2. encourage honesty from doctors (it’s easy to tell a lie and make tall claims in the four walls of the clinic, but doctors cannot get away with falsehoods online!) 
3. ensure patients have realistic expectations from their doctor.

These websites will also improve the doctor-patient relationship, by allowing much more open communication between doctor and patient, by cutting out the middleman. Interacting with patients online will also help doctors to become more patient-centric and empathetic. Information Therapy - the right information at the right time for the right person - can be powerful medicine and can help to heal a sick healthcare system! Ideally, every doctor and clinic should have an online patient education resource center – and it’s becoming extremely easy and inexpensive to make sure that they do. 

Why were most doctors ethical in the "good old days"? I don’t think they were more principled or had higher moral standards! I feel this was simply because there used to be only one or two doctors in a community and patients quickly learned through word of mouth, who was good and who was bad. This ensured that doctors treated all their patients well, because they were completely dependent upon their patient’s goodwill. Rude doctors or incompetent doctors were soon booted out because patients refused to go to them !

Why do bad doctors flourish today? This is primarily because patients are clueless. It’s hard for them to get reliable feedback about a doctor from other patients. They cannot differentiate between a good doctor and a bad one because they have limited medical knowledge. However, once good doctors start educating their patients online, the balance of power will change quickly. Patients will be able to learn about their medical problems and treatment options; and will be able to quickly screen through multiple doctors online, from the convenience of their homes, so they can select the one they feel is best for them. Once patients have this knowledge and power, doctors will have to improve their bedside manners, if they want to continue to attract patients !

I feel there is no point in complaining about declining ethical standards or waxing lyrical about the good old days. Good doctors do not need to be taught ethics and bad doctors will never learn! Will my solution solve all problems? Sadly, no. There will always be greedy doctors who would rather eat cake, and it is true that many bad doctors will also have their own websites. However, over time, thanks to the negative feedback which expert well-informed empowered patients will provide online about these bad doctors, they will be forced to improve! Meanwhile, good doctors will flourish, thanks to the positive feedback their patients will provide about them. We hope that once all doctors have an online presence, this will create a win-win situation for patients and doctors, and will allow doctors to practice medicine ethically once again ! 

Dr. Aniruddha Malpani is a renowned IVF Specialist based out of Mumbai, India. He also runs the world's largest free patient library - HELP (http://www.healthlibrary.com). Dr. Malpani is also a Director on Board of a series of healthcare organizations and websites. He can be contacted at info@dr.malpani.com