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Medical malpractice

August 17, 2012

AN elderly relative was having severe chest pains. We took him to a well-known private hospital nearby. The doctors thought he had had a heart attack and wanted to admit him immediately and schedule a bypass.

The relative, feeling stable enough, decided to get a second opinion from a specialised public-sector cardiac institute. The doctors at the institute advised him not to go for a bypass as they thought his heart was too weak for it. With medication, they said, he could have a reasonably comfortable and active life. He chose the latter.

Was the advice of the doctors at the private hospital their best professional advice? Or, since they stood to gain financially from the bypass, were they loading the dice in favour of it and willing to perform a major surgery where the burden of the risk fell on the patient completely?

We will never know. But my relative was happy he consulted the second team and always felt he had made the right decision.

Medical malpractice is quite common in Pakistan. From over-testing, over-medication and doing excessive surgical procedures for making extra money to negligence (such as leaving a sponge in the stomach during an operation), not following standard procedures and indulging in outright criminal behaviour, our newspapers report cases of all sorts. But seldom do we hear of these cases being fairly, promptly and adequately investigated and dealt with by the administrative or judicial system of the country.

Medical malpractice or negligence is a problem across the globe. The core issue is information asymmetry, and that is inherent in exchanges in the medical setting. When you go to the doctor for diagnosis, she has knowledge you do not. How do you know she is using her knowledge to the best of her ability in your interest? What if her interests are not aligned with yours or she is just careless? You could always go for a second opinion, but if you have two different opinions, how do you decide which one to follow? Even if they are the same, how can you be sure they are right? Should you go by the most common opinion?

There are a number of ways various countries have tried to reduce the risk of malpractice. It cannot be eliminated, as the risk of mistakes and errors of judgment will always be there even if factors like self-interest are removed completely. But most large hospitals have strict standard operating procedures that are checked and evaluated by third parties: professional bodies of doctors and other medical staff, state authorities, and insurance companies.

The motivation for having strict procedures might be the fear of legal or administrative sanctions, which are available quite readily to aggrieved parties, but it works to a significant degree. Professional bodies have strict codes of conduct too and do take action in cases where medical professionals breach them. The reputation of each of the institutions involved is also a stay against opportunistic behaviour on their part.

All of the above raise the administrative burden and cost of medical practice significantly. They also sometimes encourage excessive testing and risk-averse treatment, but they do make the patient a lot safer and allow them to feel more protected. The more risky and less established procedures and medical options are sometimes still available outside the mainstream. But these are usually advertised as such and are not covered by mainstream insurance companies. So if patients still choose to go for these, they are likely to be well aware of the option they are taking and the risk they might be running. Even in these cases legal remedies against malpractice are still operative and available.

Even after all of the above and other protocols and protections, some estimates have shown that the health service in UK still faces a 10 per cent medical negligence rate. And other developed countries have comparable statistics. Though we do not keep any statistics, nationally or even regionally on the issue, given the lack of protection it is very likely that the rates are much higher in Pakistan and the nature of negligence or criminal activity is more severe, with more serious consequences for patients.

To lose a loved one is hard enough. To have the feeling that the loved one was lost due to a mistake that a professional made or the greed of a professional is a tragedy that should never happen. But it happens far too often in Pakistan.

To err is human and we cannot remove the possibility of errors completely. But we can build protocols that reduce the possibility of errors to a minimum while keeping costs and other variables in mind. And we can build protocols that eliminate conflicts of interest: profits for doctors or hospitals should not be guiding decisions regarding our health and well-being. But for this we have to take a number of steps.

The law on malpractice and negligence has to be tightened, implemented better and made more effective; maybe we should have separate benches that look at this issue. But the law, however efficient, will not be enough. It should be more of an encouragement for hospitals and for associations of doctors and other medical professionals to develop internal systems, standard operating procedures and protocols that reduce the incidence and possibility of negligence and punish it when it happens.

However, this step is unlikely to be taken by these organisations without the law and the regulatory set-up of the state coming down hard on them. The real problem is that despite the return to democracy and the recent changes in the judiciary, our institutions have not done a credible job of legislating on and implementing effective regulation or providing effective judicial recourse in any area.

The writer is senior adviser, Pakistan, at Open Society Foundations, associate professor of economics, LUMS, and a visiting fellow at IDEAS, Lahore.

fbari@osipak.org