A New Prescription

With the perception of malpractice rising, the doctor-patient relationship faces the test of faith. It’s time for both society and the medical world to talk and introspect

Seventy-one years after Independence, as we revisit today what independence and autonomy mean to us in both conceptual and practical terms, a reminder of the fact that rights and responsibilities go together is perhaps needed. On that note, we may want to look at what the contours of those rights and responsibilities look like in the context of a doctor-patient relationship. The interaction between the two is indicative of more than just what is happening in the interspace of the doctor and the client. It is also reflective of the larger societal and legal influences which will inevitably influence the interaction. So, the sense of autonomy that the patient has in the clinical encounter will be determined by how society views the doctor. Equally, the sense of urgency, whether participative or uni-directional, that the doctor has in this encounter is influenced by many things, including legal provisions.

The nature of conversations between society and medicine can be a source of endless fascination. Modern-day society in India veers perhaps between the binaries of looking at the medical profession on the one hand as the fount of all wisdom and caring, expecting it to explain everything from road rage to global warming, acting forever with selfless dedication and, on the other hand, seeing the medical profession as moneymaking and predatory, being exploitative of both illness and suffering. In turn, the medical profession also seems to oscillate wildly between vastly differing positions. At

one level, there is an inherited altruistic, humanitarian position, where the doctor sees himself as duty-bound to offer care and succour to all who are in need, especially the poor and the disadvantaged. At another level, there is the lure of lucre, as it were, with ostentatious consumerism a hallmark of modern society. The tensions between the humanitarian ideal of service and the professional pulls of the increasing corporatisation of medical practice are often difficult to resolve.

The fact is that most medical care actually happens in the private sector in India, and that medical insurance or employer-funded insurance actually covers only a small part of healthcare. So most healthcare costs end up by being borne as ‘out-of-pocket’ expense. The theatre of this care is mainly clinics, nursing homes and hospitals big and small across the country. The other part of this is that effective regulation of medical practice has not been really in place. The main regulatory body of medicine, the Medical Council of India (MCI), has scarcely covered itself in glory. The professional associations, of medicine, unlike say in Britain, have neither regulatory nor licensing authority. So, a psychiatrist in Britain is licensed by the Royal College of Psychiatry, but in India, the Indian Psychiatric Society does not license the psychiatrist, the MCI does. Therefore, the professional bodies can make recommendations, draw up guidelines for practice, and this is indeed their mandate, but their mandate is also to concern themselves with the interests of the members. This goal, the interest

THE TENSIONS BETWEEN THE HUMANITARIAN IDEAL AND CORPORATISATION OF MEDICARE ARE OFTEN TOUGH TO RESOLVE

of the practising doctor and the interest of the society that the doctor treats, is certainly not always going to be the same. So while combining the two is certainly the overarching mandate, the question is how effectively does this happen. It may also be important to remember that to practise as a specialist in India, the doctor does not need to actually be registered with the professional association. An MCI registration is good enough. In this scenario, the regulation of practice is often left to the individual practitioner.

The fact is that, on the whole, medical practice, undeniably, is generally good. The majority of physicians will certainly act with the good of the patient in mind, and the patient, who puts his health and his trust in the care of the physician, will certainly find his trust rewarded. The care will be thoughtful, and the decisions in the interest of the patient. It has equally become clear that, sometimes, this trust will be misplaced. Unnecessary investigations will sometimes be ordered, needless procedures prescribed, cut-practices will happen. Some prescription will be irrational. It is these instances of medical cupidity that have, in a sense, thrown the larger section of well-intentioned practice in a rather troubling light. The growing concerns about medical malpractice, the way that courts and indeed society are prone to take a critical stance of medical practice are perhaps indications of this. It is also reflective of a growing sense of cynicism, a sense that the systems are not doing enough for the individual, and a greater emphasis on the importance of the individual—a shifting of the gaze from the collective to the person.

In a sense, this is symbolic of an increasing level of litigiousness of society, and at another level it is an understanding that the selfregulation that any profession should have is perhaps not being seen to happen. While at many levels this shift is perhaps inevitable, as we move to a more ‘rights-based’ approach, at another it highlights the flip side of the shift—a growing sense of alienation and unmet need.

Today, as we have many discussions on what freedom and autonomy mean, it may be wise to deliberate on what sort of discussion the medical community has, at one level, within itself, to interrogate its own motivations and self-regulatory mechanisms, and with the larger societal structure. In the discipline of psychiatry, this discussion becomes of even more importance because this is one discipline where societal constructs are influential. Mental health legislation is specifically a case in point. So where society draws a line as to the acceptability of behaviour becomes important for psychiatry.

If one accepts the reality of mental illness, then the possibility that some people, at some points of time—because of their disorder—may require ‘involuntary’ or ‘supported’ treatment for short or long periods of time needs to be considered. This, the regulation and safeguarding of the individual’s rights at the time when he is involuntarily being treated, constitutes the core of mental health law. Also, the demarcation—when to decide that this is needed, who decides this—the doctor, the family, the court, or a committee—are issues that all societies deal with. As we move to more individual rights-based approaches, discussions on when intervention is possible or needed will move apace with discussions on the possibility of abuse of rights when the person is admitted. The right to appropriate treatment will also be have to balanced against the right to refusal of treatment.

Another case in point is the deeply fascinating concept of what is called the ‘advance directive’ in psychiatry. With this, the individual in times of clarity and well-being decides what can or cannot be done with him in times of possible future incapacity. So, effectively, I say that if I do happen to fall sick with a mental illness, then I decide how I should be treated. Based on the concept of the ‘Ulysses contract’, from Homer’s Odyssey, when Ulysses asks his crew to row past the Isle of the Sirens, with beeswax in their ears, it is conceptualised as a bipartite contract between the individual and the treating team. However, in actual practice, it raises many interesting and intriguing questions—which self is the deciding self, how can one self decide for the other, when can it be revoked, and the fact that when we change this to a tripartite contract between the individual, the doctor and the law; what happens then, are conversations still waiting to happen.

THE CONCERNS ABOUT MEDICAL MALPRACTICE ARE REFLECTIVE OF THE PREVAILING CYNICISM, OF A SENSE THAT OUR SYSTEMS ARE NOT DOING ENOUGH FOR THE INDIVIDUAL