Sunday, July 9, 2017

An ethical dilemma

by Lakshman I. Keerthisinghe-2017-07-08

When we are sick, we want an uncommon doctor; when we have a construction job to do, we want an uncommon engineer, and when we are at war, we want an uncommon general. It is only when we get into politics that we are satisfied with the common man.
– Herbert Hoover

It was reported in the media last week that State hospitals in Sri Lanka were paralyzed as doctors went on strike to demand that a private medical university be shut down, saying it could jeopardize health care standards in the island. The strike affected thousands of people as State-run hospitals were unable to provide outpatient treatment or perform routine surgeries. Doctors were still treating patients needing emergency or critical care, as well as children and pregnant women. Cancer hospitals and kidney disease treatment units were also still operating.

The private South As

ian Institute of Technology and Medicine (SAITM) has been at the centre of a controversy since its establishment in 2008. It is the only private university training medical students in Sri Lanka. Students at State-run medical faculties and government doctors say the private medical school does not meet the country's educational standards, which the private school denies. Doctors and students also say the existence of the private school could jeopardize the country's decades-long tradition of offering health care and education for free.

Storming Health Ministry

It was also reported that students from State-run universities stormed the Health Ministry to demand the private university be abolished, and were met by Police who swung batons and used tear gas and water cannons. Dozens of students were injured. Doctors at State-run hospitals urged the government to take action against those who ordered the Police crackdown. The Government Medical Officers' Association (GMOA) vowed to continue its strike until the government complied with its demands, while SAITM medical students have been embroiled in a legal battle to be permitted to practise medicine, after the Sri Lanka Medical Council (SLMC) denied them certification as doctors.

It is interesting to note that in March this year "The Hindu" reported that in India in a case involving the Maharashtra doctors' strike, the Bombay High Court directed the hospital managements to take disciplinary action. In this case a resident doctor at Sion Hospital was allegedly assaulted by the relatives of a patient who died a few hours after being admitted. A resident doctor in Dhule civil hospital was brutally attacked when he suggested a patient brought with head injury be taken to another hospital since they lacked neurosurgeon's expertise. Forty-nine doctors have been attacked in Maharashtra alone since 2015. Doctors in Maharashtra launched a state-wide protest since the Sion Hospital incident and they've been getting support from their medical fraternity across the nation. As doctors were on mass leave, thousands of patients at public hospitals were inconvenienced. Surgeries were cancelled, several patients were turned away from Out Patient Departments (OPD) and only emergency cases were being handled.

Disciplinary action

The Bombay High Court directed the management of government hospitals to take disciplinary action against around 4,500 doctors who are on strike for the second day in protest against attacks on two doctors last week. A Division Bench, comprising Chief Justice Manjula Chellur and Justice G.S. Kulkarni said contempt action should be taken against the striking doctors. If regular doctors are working, then how can the resident doctors fear for their safety, the Court observed. "It is a shame on the profession if doctors go on strike like factory men, then they are unfit to be doctors," the Court said. ''What will doctors do, if people thrash them in their rooms.

If doctors want to continue their strike, then they should stay 100 feet away from hospitals, so that visiting patients can get treatment without any difficulty."

Referring to both the cases where doctors were attacked by patients' relatives at Dhule and Sion, the Court asked whether a dead person's life will come back if they kill the doctor. "Why this public anarchy, it is only madness." The court noted that there could be some cases of negligence by doctors, but mistakes may occur due to reasons such as allergy reactions and every case cannot be treated as medical negligence. Patients' relatives should not resort to extreme steps always, the Court pointed out. On 4 May 2016, a representative of the Maharashtra Association of Resident Doctors (MARD) filed an affidavit in the Bombay High Court, stating that the Association would not resort to strikes. It also said in 2015, there were at least five instances where resident doctors were attacked or beaten up by patients' family members and were verbally abused for no fault of theirs. In spite of being aware of the dangers the doctors faced, the State government was yet to come up with an action plan to prevent such incidents, the affidavit added. The Court was hearing a public interest litigation (PIL) petition filed by RTI activist Afak Anwar Mandaviya. It stated that MARD supported the strike by doctors that took place last year and sought criminal action against them.

Right to life

Unlike in other cases of trade union action, strikes by doctors affect human lives. Thus, the right to life of human beings is threatened by such strikes while other strikes involve only financial or economic losses to the state. It is time that legislation was enacted to make the medical service an essential service permanently or declare it as such with the attendant penal consequences for default in appropriate circumstances.

The Hippocratic Oath is historically taken by physicians. The oath is the earliest expression of medical ethics in the Western world, establishing several principles of medical ethics which remain of paramount significance today. These include the principles of medical confidentiality and non-maleficence. Although the ancient text is only of historic and symbolic value, swearing a modified form of the oath remains a rite of passage for medical graduates in many countries. Hippocrates is often called the Father of Medicine in Western culture. The English translation of some parts of the earliest surviving version of the Hippocratic Oath, originally in Greek is as follows:

"I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing....Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free....Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I transgress it and forswear myself, may the opposite befall me."

Intentional wrong-doing

Strikes by the medical profession entails intentional wrong-doing and harm as the doctors are well aware that abstaining from treatment of sick persons who come to hospitals seeking treatment as such persons are poor and have no other means of treatment would harm their well-being and health.

The government also should require the medical graduates who pass out of State-run medical faculties to enter into a bond of minimum ten years duration to serve the public or reimburse the State for their free medical education. The striking doctors must realize that they continue to receive payment of their salaries from public coffers even during the period of strike.

In conclusion, it must be stated that it is pathetic that the government medical officers engage in such disruptive activities placing the poor masses in such misery at the drop of a hat without any care for their suffering. Although it is stated that their efforts are to prevent the patients being subjected to treatment by unqualified persons, there is recourse to the law to prevent such persons from practising rather than actually placing the patients in jeopardy by periodic strikes.

The writer is an Attorney-at-Law with LLB, LLM, MPhil (Colombo)