ACCORDING to Greek physician Hippocrates, whereas life is short, medicine is a long art. As physicians, for many of us this is as true today as it was then. And despite the advances in scientific knowledge and biotechnology that have irrevocably changed the nature of medicine since Hippocratic times, a constant remains the central role of patients in the education and training of physicians.
William Osler, a 19th-century physician, stated correctly that while books are needed to chart the vast sea of medicine “he who studies medicine without patients does not go to sea at all”. So when physicians proclaim that it is patients who need them they tell only half the story. The ignored half is that the existence and continuation of all aspects of medicine — our education, experience and skills, clinical practice and biomedical research — would be impossible without members of the public serving as patients and research subjects.
However, this symbiotic relationship between two sets of human beings — physicians and the public — has been reduced to one in which the latter are used as a mere means to further the ends of the former. Our health systems are replete with examples of an unethical, callous approach to patients in which the latter’s dignity and rights are trampled upon in multiple ways. Medical language itself reflects the objectification and dehumanising of patients.
####Bioethics continue to elude our doctors in the treatment of patients.
In medical colleges, they are often referred to as teaching ‘tools’ or ‘material’ for educating students, terms which disembody and reduce individuals to biological diseases divorced from human identity. It is not uncommon to hear medical students and trainees identify patients as the ‘case with hot cholecystitis on bed 3’, or the ‘huge abdominal mass in ward 2’,’ or ‘bed 10 with amazing arrhythmias of the heart’.
When bara doctors (consultants) with white-coated residents cluster around ward beds for teaching rounds their discussions are in English, incomprehensible to many patients. One after the other, students are summoned to demonstrate ‘interesting findings’ on the patients lying nameless and mute before them. No effort is made to greet the patients by their names, explain anything, or seek their assent before laying bare their bodies for scrutiny.
When questioned, physicians generally say ‘they (the patients) know this is a teaching hospital when they come for treatment. After all, we have to train our doctors’. The irony is that within the private wards of the same ‘teaching’ hospitals patients are treated with deference and students’ access to them is restricted.
Patients are also mistreated when used for clinical specialty exams that must be passed to qualify as medical specialists. In the absence of paid volunteers trained to serve as ‘simulated patients’ on whom affluent countries increasingly rely, in Pakistan real patients are selected from public hospitals and bussed to examination centres. Speaking with them reveals the extent of deception and disrespect in this practice.
They aren’t told they will be used to assess the training of nervous doctors, and their permission is not sought for this purpose. In fact, patients are generally told they are being taken to be examined by a ‘big’ doctor in another hospital for their own good. In reality, as the exams extend over many hours patients suffer rather than benefit.
Technological advances have accelerated the trend among physicians to photograph and make video recordings of their patients. These are shared with each other through social media, used in the press and on billboards to raise hospital donations and zakat, and featured at conferences. No attempt is made to obtain the patients’ consent or to take appropriate steps that ensure dignity and safeguard privacy and confidentiality. It would not be wrong to say that few if any of us would allow our family members to be used in this fashion.
Another emerging practice is to invite ‘renowned’ international surgeons to undertake dramatic live surgical procedures broadcast to hundreds of participants in auditoriums. This too raises ethical concerns and the possibility of causing harm to patients when teaching is combined with patient care. Last year, a live liver resection demonstration by a Japanese surgeon in a workshop organised by the All India Institute of Medical Sciences in India ended in the death of the patient. The case made headlines and is under investigation.
Clearly, it is indigent patients from public hospitals who are selected for live surgery; it remains unclear whether a fully informed, detailed consent is obtained from them and their family.
With the tremendous physician-patient power differentials in our region indigent patients are less likely to question or even refuse permission for live demonstrations in which details of their medical history and bodies will be broadcast to strangers. The potential for exploitation of patients through this practice has led the British Medical Association, and others, to constitute ethical guidelines to which our physicians remain oblivious.
We forget that the practice of medicine is always a moral undertaking. Neither institutions such as the Pakistan Medical and Dental Council and College of Physicians and Surgeons, nor the medical community and their professional organisations appear to understand this. Except for a few medical colleges none allocate time in their curricula to teach students even the rudiments of medical ethics.
Ethics guidelines prepared by the National Bioethics Committee of Pakistan to correct this curricular deficiency have received no attention from PMDC despite multiple attempts. Workshops for medical trainees continue to focus only on scientific methodologies of human research seemingly unaware that unethical research is bad research.
Pakistan has some of the most ethical, caring physicians I know. But many remain silent spectators, wringing their hands that nothing can be done. This will be a self-fulfilling prophecy unless physicians realise that their responsibility is to help produce not only skilled technicians but also ethical healthcare professionals. Hippocrates also believed that to the love of her/his profession “the physician must also add the love of humanity”.
The writer is chairperson, Centre of Biomedical Ethics and Culture, SIUT.
Published in Dawn, February 29th, 2016