Saturday, June 21, 2008

Modern Day Medicine Men: Hypocrites or Hippocratic?

“If medicine were simply a matter of prescribing drugs and wielding scalpels, then monkeys—or at least robots—might make adequate doctors. It's the human bit, as in most enterprises, that makes medicine tricky, fascinating, and difficult.” ~ Dr Richard Smith, Editor, BMJ June, 2004

“Humans must always be the subjects of rights, must be ends, never mere means, never objects of commercialization and industrialization in economics, politics and media, in research institutes, and industrial corporations. No one stands ‘above good and evil’ – no human being, no social class, no influential interest group, no cartel, no police apparatus, no army, and no state. On the contrary: Possessed of reason and conscience, every human is obliged to behave in a genuinely human fashion, to do good and avoid evil!” ~ Hans Küng – Karl-Josef Kuschel (Eds.), A Global Ethic. The Declaration of the Parliament of the World’s Religions (SCM Press, London / Continuum, New York 1993).

“Come One! Come All! Come and get this fantastic Snake Oil! It’ll cure anything, indeed everything!”

So cried the snake oil medicine men of yesteryears, and indeed similar clichés resonate these days, cloaked under newfangled technologies, fringe pseudo-scientific claims and cleverly camouflaged advertising gimmicks—straight to the consumer—bypassing the meddlesome medical fraternity and ethical do-gooders, or so it seems.

Healthcare services and products are an increasingly attractive sector for the market economy to penetrate and so many are now targeting these as test grounds for making a quick buck.

Direct marketing and multi-level marketing (MLM) of healthcare consumer products such as supplements, vitamins, herbs, and even dubious alternative “medicine” gimmicks are making strong inroads in Malaysia, enticing and embroiling not just the gullible and the less educated, but so too, many literate New-Aged people who are confused as to what is true science from what is pseudo-scientific nonsense.

Homeopathic, complementary (traditional) and naturopathic claims are supplanting scientific (allopathic) medical thinking and vying for public credibility as well as for consumers who are becoming simply too bewildered to know whether these are truly useful, beneficial or otherwise. Which should be the better proven or indeed the rational choice is becoming harder to fathom for the ordinary man in the street.

To make matters worse, many newspapers and newsmagazines from the well-established to the local vernacular press have been blatantly offering devious advertorial messages, which imply that many unfounded alternative therapies are sound and reasonable.

The Star, in particular, is quite notorious in its avant-garde action for promoting alternative therapies and supplements—it regularly devotes tens of pages to so-called “health information” which are frequently inappropriate and often misleading, but which pander to public voracity for quick and simplistic cures, contemporary if unconventional ideas.

Worse, in its attempt to appear fair, it also intersperses medical and health facts amidst these pages of highly ambiguous and contentious information. This lends undue credibility to poorly justified “alternative therapies” and totally confuses the unsophisticated reader.

Of course, there is that unqualified disclaimer being attached to all such missives, as if these could then exculpate their guilt in promoting such a retrogressive step for humankind. But then, there is that almighty advertising dollar to contend with…

Since these subliminal ‘factoids’ have appeared in the press or the media, then they must have some elements of truth in them, so the thinking goes. Sadly, such is the din of the current state of affairs that scientific truths are becoming drowned out and are being displaced by these bogus and downright magical thinking!

This is no small matter because Malaysians spend some 3 times more on alternative healthcare products than on actual allopathic health products or medicines—the latter of which include such expensive medicines as for HIV/AIDS, cancer or heart problems!

Malaysians, it seems, prefer to self-medicate and view such unassuming supplementary “medicines” and herbs, etc. as sufficiently “harmless” to combat whatever possible ill-health that may be forthcoming—“no harm-lah, just for health promotion only; besides they are all safe for my body, no side-effects like western medicines which are all poisons!”

Sadly when such phony claims prove to be neither beneficial nor to do anything beyond the placebo feel-good effect, they are dismissively shrugged off as acceptable—“just preventive only, sure cannot guarantee no health problem in the future”.

Contrastingly, they are less generous when it comes to western medicine, where they expect cures every single time, and are disproportionately worried about adverse effects—“my kidneys, my liver, will they be damaged?”

Yet with herbs, roots, and other so-called natural products, they are willing to accept their safety wholesale, without checking on their authenticity, purity or better yet their purported benefits—seemingly believing in simplistic anecdotal stories as living proofs.

Into this mindset, we are thrust the onus of explaining the more esoteric science of modern medicine which appear outside the realm of antiquated but deep-seated system beliefs such as humours, qi, angin, even charms, pukau, etc. Doctors have also to compete with sinsehs, bomohs, dukuns, Ayurvedic doctors, Qi Gong masters, and the occasional itinerant snake-oil medicine men.

Lately, more enterprising homeopathic and naturopathic advocates have been stridently proclaiming their expertise through paid advertorial pages, and promoting health supplements and natural therapies without the threat of ethical misconduct that doctors would be subject to.

Lopsided as this may seem, modern medicine would still have to maintain an air of sophisticated distance if for no other reason than to be prudent and not to be drawn into a war of ideas, which might have to be fought on unequal terms and widely-divergent playing fields. Or perhaps scientific medicine is simply too superior…

Of course, this does not imply that we would have been guaranteed adequate or fair hearing if we had chosen to be more vocal about truly scientific concepts.

Notwithstanding this, most mass media are ever willing to be more objective, and are often looking out for authoritative and scientific expositions, from doctors and scientists alike. The trouble is that there are not enough of us willing to devote our time and effort to correcting or informing the public about what’s new, current and yet factual.

Nevertheless, we can do better and should be more proactive in debunking falsehoods when they occur, so that we have at least tried to put the record straight.

So we have here an underlying crisis of confidence in the system of healthcare and medical practice, which would take time and a lot of concerted effort to correct or improve.

Then, we face another very damaging challenge from within our healthcare affiliates. Instead of complementing our work as health care providers, retail pharmacists and pathology laboratories have increasingly become our direct competitors for patient access.

This asymmetrical problem arose because doctors in Malaysia are still tasked with the dispensing of medications instead of just prescribing. And there is simply inadequate policing of the pathology laboratories without a Medical Pathology Bill with teeth!

There are valid issues behind the arguments for and against this practice of doctor dispensing rights. However, it will remain unresolved until we have sufficient retail pharmacists willing to be posted throughout the entire country including rural locales; and doctors feel comfortable that they can earn their fair remuneration of professional fees, which in time our patients feel duty-bound to reimburse.

Hence, we are seeing a new breed of retail pharmacists who have become embolden to challenge the mystique and realm of the medical practitioner. Unscrupulous advertising and blatant canvassing for patients, with billboard claims of cheaper treatment for coughs and colds, free blood tests and BP testing are enticement gimmicks now increasingly prevalent.

Many a retail pharmacist blatantly sell prescription medicines (with discounts, and other offers) without prescription orders from doctors, and some even change the medications to those available at their stores (often generics of unsure quality or parallel imports), with no reference to the doctor concerned—in other words they are behaving as if they are medical practitioners—except that they are unlicensed and untrained.

Of course, this is not true of every pharmacist out there, and that these might only be a minority. However, those few who totally disregard this professional breach, continue to flout the regulations with impunity because we appear powerless to police their actions, through the inadequacy of our pharmacy surveillance and implementation units. As a result, some of our doctors are feeling the looming effects of such unfair competition.

Doctors feel frustrated that they are unable to offer cheaper prices on medicines as this would bite into their cost of running a medical practice, with rentals, incidentals and personnel to take care of.

We are also aware that pharmacies are able to offer differential discounts and then pad their earnings from sales of other supplements and other consumables where the profit margins are better.

So what do the poor out-competed doctors do? Although a very small minority, some have taken the easiest ways out—selling medical certificates, cough mixtures to drug dependents, hiring unqualified medical assistants, etc.

They too are resorting to pushing consumables, supplements, vitamins and even MLM products under the guise of healthcare use. Indeed it has been strongly suggested that within their clinic premises, some medical practitioners are profiting much more from such commercial enterprises than from practising medicine per se!

Many doctors are ‘diamond’ and very senior level dealers of MLM products which are health-related but largely unfounded in actual science.

While we cannot deny the medical practitioner his or her right to be involved in business, there is an extremely thin line of moral uncertainty where he or she can practice such an enterprise.

Furthermore, it could be construed that this breaches our ethical code of using uncalled-for enticement and market practices to attract patients, or using our professional position, premises and undue influence in society to enhance our financial gain with questionable commercial undertakings quite outside the ambit of medical practice.

These are contestable ethical conundrums which we can and should do without, because they can lead to accusations of serious professional impropriety and ethical misconduct. Yet there are many younger physicians out there who increasingly feel that we have become too rigid and old-fashioned, too much bogged down to our past glories and ethical millstone.

Are we too sanctimonious and out of touch with the modern market economy?

Are we all hypocrites since we are all human and hanker after the same pleasures, the same conveniences, the profit and the good life?

Should we allow our superimposed altruistic self to supersede our post-modern culture—where man is suppose to surpass himself, to attain a Nietzschean superman status?

So what can medical practitioners do in such a state of heightened competition for more attention from the consumer out there?

How indeed should we stay relevant and needed, and yet be practising within the ethical boundaries of our medical profession?

It is true that we are, by and large, still much respected as honorable professionals, but there is no denying that we are losing our grip with the public’s trust and dependence on us.

Still, is becoming more commercially-orientated the answer? Or are we beating about a lost cause in this new era of market-driven economy?

As increasingly astute consumers, our patients are constantly bombarded with indiscriminate and baffling information from diverse sources all purporting to enhance their health and well-being.

Thus, patients are inexorably thrust into seeking alternative ways to empower themselves with decisions about their own health care needs.

The mass media can of course help to alleviate the situation by being more selective in their portrayal of all such sundry health information, as incontrovertible scientifically-proven facts.

A watchdog committee should vet what constitute ethical and scientific medicine or healthcare, and clearly delineate those that are fringe or borderline alternative therapies or complementary practices into a separate well-demarcated section.

We must separate the wheat from the chaff, if the mass media strongly considers alternative therapies as must-publish entities because of public or commercial demand—but they should state this so as clearly as possible.

Pharmacists should be constantly reminded, educated and re-orientated to stick to their own ethical boundaries. They should use their training to educate their patients with sincerity and assist the medical practitioners for the betterment of the patients and consumers.

Supplements should be labeled as such and not be given undue emphasis or weight to enhance their unproven value or benefits, just for the sake of monetary gain.

Family doctors must practice restrain and high resolve to steer clear of unprincipled or ambiguous actions which can breach their code of ethics.

Specialists must refrain from offering too much service—over-prescribing, performing unnecessary surgeries or investigations or over-utilization just for the sake of profit. They should also refrain from overstating their expertise, or over-performing their limits or skills.

Informed consents should be more rigorously employed so that our patients are better prepared and educated as to risks and benefits—more sensible and satisfactory expectations can then be made—with fewer need for dispute resolutions and unhappy consequences.

Grandiloquent promises should be avoided as these breed unrealistic expectations and demand for unnecessary, costly and futile management strategies and cost-inefficient catastrophic surgeries.

Unfortunately, fighting for the soul of our patients’ thinking and trust is an ego-shrinking game in this new era of easy and ubiquitous knowledge largesse.

As doctors we must learn to acknowledge that we no longer have the sole control of such health-related information. But we can channel our paternalistic energies and informed training into authoritatively educating our patients out there so that they can make correct and more rational choices. Still, this is where serious divergences in approach occur.

With commercial pressures and money-making enterprises beckoning in the tempting horizons, many are adopting increasingly dubious practices to regain the ‘personal’ touch and connection with our consumers.

This is where some physicians have begun indulging in integrating untried and untested alternative therapies to gain wider patient acceptance.

While properly trained acupuncturists can now be considered part of integrative medical practice, other quasi- and pseudo-medical quack practices should be scrupulously avoided and shunned.

Sadly instead, we are seeing more and more clinic practices incorporating seriously doubtful therapies such as chelation therapy, ozone therapy, rejuvenation therapy, iridology, aroma therapy, hydrotherapy, cleansing therapy using colonic washouts, beautification boutiques and salons, etc.

What happened to our rigorous medical training that we should have become so easily beguiled with superficial beliefs in the ‘occult’, the ‘magic’ and the quackery of fringe practices which have no bases whatsoever in science or scientific thinking?

Why have some of us become so credulous or as gullible as some of the lesser initiated in scientific literacy or medical or healthcare education?

Is it the whimsical wish to distinguish ourselves for a niche market, is the commercial lure for lucre so strong, or is it simply a wish to be different?

But surely, in my mind, such practices cannot ever be construed to be smarter or more reliable than the orthodoxy of medical science currently at stake.

Either we accept medicine as an evidence-based evolving science or we can decide to leave this science and join the pseudo-science—but abdicate we must—we cannot fuse these two disparate systems, and jeopardize our medical fraternity and professionalism.

Quackery combined with some aspects of medical science only demeans our professionalism, and shortchange our scientific approach to life and living.

We can only be deceiving ourselves by selling our soul to the darkness of ignorance and remitting our minds to the forces of anti-science, perhaps just for some erstwhile 30 pieces of silver…

Conversely, this is also where as per our medical professionalism, we can show that we are better than we should be—and regain our patients’ eroding trust in us.

While it is true that nowadays more than ever, the medical profession is pressured to become an integral part of the business world, one that is market-driven and which adapts to consumerist demands and expectations; it is also true that we have to be very mindful as to our professional calling.

It is true that the motto “if you can’t beat them, join them” runs deep and is increasingly permeating our medical circle. It is also true that in trying to determine our rightful place in today’s society, doctors have become torn between the ethical confines of the Hippocratic Oath and their drive to be successful individuals traipsing among the maze-fields of widely-disparate economic activities.

Some conservatives among us are righteously adamant that the medical profession remains totally detached from commercialism, and that it should not become another trade enterprise subject to the vicissitudes of supply and demand, with its various proclivities to mercantile aspirations and buyer-seller, provider-consumer mindsets.

They maintain that we remain the noble profession which has persisted since time immemorial, with the highest of ethical standards, which should not become tainted by venal interests and scurrilous profit-orientated motives.

I believe we must actively remind ourselves that such questionable actions must be consciously eschewed, and we should not become drawn into their tantalizing tentacles of self- or financial interests.

Not only that, we must also shield ourselves from the encircling vultures of market-economic interest groups, etc. which are constantly bombarding us with seductive attractions, allurements and temptations to slide down the slippery slope of commercialism.

Again and again, we may be tempted to unwittingly slip into ethical transgressions which become with time, more inchoate and less conscientising. Ultimately these can become entrained into acceptable if morally ambiguous behaviour.

Yet we must uncompromisingly remind ourselves that we are medical professionals first and foremost, with a moral imperative to consider our patients as our raison d’être.

We must therefore set our ethical standards purposefully and exceptionally high to constantly kindle the embers of our moral rectitude and probity, without which we stand to fall deeper and deeper into the hubris of uncertainty and moral conundrums and depravity.

One of the problems of modernity is that we have been exposed to the relentless onslaught of technological and economic progress which has generated a callous climate of demand creation and amoral craving for more and more—a consumerist mindset which is inexorable and insatiable.

We are forced into a struggle of Faustian proportions, with less than certain anchors for which to judge what is proper and right. I do not believe we are as yet doomed to a Mephistophelean future.

In his 1993 Ethics lecture to the American College of Surgeons, Dr Leffal reminded medical doctors that “high ethical principles represent the grace notes of our profession and involve not so much intellectual rigor but a disciplined spirit. Ethics represents not just what we do or what we say but what we are… What is important in our practice is something the Romans called ‘gravitas’—moral and temperamental weight—that binds us in an ethical way to our patients.”

Edmund Pellegrino, a noted medical ethicist, defines ethics as the science of human conduct and that medical ethics refers to the whole medical arena—including care of the sick, prevention of illness, and cultivation of health for individuals and society.

He advocates strongly that ethics as a discipline with its own content and method can be taught. He believes that ethics encompass certain but concrete human judgments in various situations where actions have to be taken, in spite of all the multifarious uncertainties and inexactitudes that are integral to clinical medicine.

To inculcate medical ethics, several objectives are realizable; these include: (1) teaching the skills of ethical analysis essential to making medical moral choices, (2) raising sensitivities to ethical issues in everyday clinical practice, (3) enhancing critical reflection on one's personal values and obligations as a physician, and (4) identifying the substantive ethical assumptions underlying clinical decisions.

Pellegrino believes that medical ethics can be reconstructed and must be based on the “one irreducible foundation of all clinical medicine—the relationship between the one who is ill and the one who professes to help and heal.” This article is written to highlight these objectives and to remind us that medical ethics stringently applied as they have been are still relevant today.

True, these days the ethical issues confronting the medical profession have become more numerous, tenuous, and amorphous—often defying or obscuring ethically correct or black-and-white answers. Some of the pat answers to many a searing ethical question seems to lack the moral symmetry that fairness demands.

Nevertheless we must choose to remain steadfast in our devotion to higher ideals and principles if we are to give our patients the best care that is their just due. We must steer clear from our own personal or financial interests and possible gain, which can corrupt our souls surreptitiously.

Since its founding in 1987, the Josephson Institute (in America) has advocated that civil society be built upon a foundation of 10 consensual ethical values: honesty, integrity, respect, caring, fairness, promise-keeping, pursuit of excellence, civic duty, accountability, and loyalty.

It is perhaps timely to remind ourselves of what these ten values mean to each and every one of us, individually. We cannot and should not pick and choose, when and where or how and what, but we should encompass all these into a rational whole—an entity which is above the human weaknesses of expediency, complacency, compromise or hypocrisy.

What then, is our charge as doctors? It is simply thus: to cure when possible, to relieve pain and suffering always, and above all to do no harm, to our patients in particular, and to society in general.

Sometimes we fail in our charge, but when we fail and if we fail, we must always fail while trying. Yet pragmatism dictates that some prioritizing of our finite and personal resources must be undertaken if we are to help the greatest number of patients.

By tempering our egotistical impulse with practical lessons in life, guided by our professional moral compass, we can then pursue our medical lives with the decent strength of a saint, and keep our business portion of our lives scrupulously away from ethically ambiguous commercial activities. If in doubt, it is always safer but much harder, to say ‘NO’.

Our continued professionalism depends on this moral anchor to which all medical practitioners are beholden. We should not waver in our adherence to the modern Hippocratic Oath, which binds all medical practitioners and this we must strenuously swear to uphold.

We must choose to be more Hippocratic in spite of all our baser tensions working against our better instincts.

“We must show … patients our sensitivity and compassion. We hear so much about death with dignity but we must also realize that there is a need for life with dignity. And dignity for our patients must be preserved. Without the moral compass of our duty and obligation to our patients, we can be hurled quickly into the abyss of inappropriate behavior. Ethical lessons loom large here. Certainly attention to caring, truthfulness, and the concept of the good of the patient come more sharply into focus. Generally, telling the truth with hope, compassion, and sensitivity seems the best course to follow in these circumstances.” ~ Dr. LaSalle D. Leffal, Jr., American College of Surgeons Philosophy and Ethics Lecturer, 1993. Medical Ethics in Today's Society.

(MMA News Editorial, October 2005)

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