“Rules of conduct, whatever they may be, are not sufficient to produce good results unless the ends sought are good.” ~ Bertrand Russell (English mathematician and philosopher, 1872-1970)
“Morality cannot be legislated, but behavior can be regulated. Judicial decrees may not change the heart, but they can restrain the heartless.” ~ Martin Luther King, Jr. (U.S. clergyman and civil rights leader, 1929-1968)
The recently concluded Deepa-Raya holidays once again showcased one of our worst Malaysian traits—our blatant disrespect for the traffic regulations and our mindless disregard for human lives and limbs.
We callously slip into our now very well-renowned baser instincts: ignoring red lights, flouting speed limits, queue-cutting, overloading, insistent me-first aggression and road-rage.
We lapse into a voodoo-like mindset and drive like obsessed maniacs not just with outrageous speed but with wanton recklessness, as well.
Behind the wheel, we seem to lose all sense of proportion and put on an animal-like persona of the possessed, and magically believe that we are indestructible, nay, immortal.
Worse, we are totally oblivious to any other driver, passenger, pedestrian or person who may chance to share that erstwhile but tragic serendipity out there—haplessly placing him or her in harm’s way.
So much so that the police and the government have instituted shamefully harsh traffic ops which purportedly are designed to change our aggressive attitude, and curb our thoughtless disregard for human life and limb.
Yet despite these measures, deaths and serious crippling injuries continue to mount, albeit at a slower rate this year than the previous year.
It appears that we as Malaysians cannot be trusted to do the right thing. While many (perhaps the majority) still drive with care and sensitivity to others—a sizeable ‘others’ seem not to respect the rules, the laws, the lives, the sanctity and rights of other fellow road users. And so the accidents, the injuries and the death toll mount with horrendous consequences for their victims and their loved ones—maimed and/or scarred forever.
Extended public holidays leave me with a sense of quiet exasperation and heart-aching foreboding, particularly when my family and I decide to rough it out by staying put in good old KL.
We decided to leave those who are prepared for the tedium and rush for home-coming to do their needful duties, but we are not joining them this time round.
Normally I would have enjoyed the quieter hours of R and R, with nary a responsibility for the day-to-day drudge of clinic work—I would just have to follow-through with my hospital inpatients and emergencies…
I would have time enough to do some catch up on my reading, perhaps some writing, perhaps the much needed mental reassessment of my hurried life thus far.
My wife calls this my mid-life crisis—and perhaps she is right. Next year I will hit the proverbial half-century, woe behold the thought! But like they say, it’s not the age that counts, but the mind. I do feel nearly always anchored at a far younger age—perhaps in the mid-thirties, frozen in time and space anatomically, physiologically, and hopefully mentally, while maturing with wisdom, patience and tolerance (ahem!). While the world continues to turn and move along, regardless…
Yet, it appears that our horizons continue to shift and change relentlessly—particularly our health care scenario and the medical profession that I had adopted as a vocation some 25 years ago.
Increasingly, the health care landscape has become unrecognizable: from passive patient-paternalistic physician knows best mindset to technologically-enhanced, mechanically-manipulated, industry-pharmaceutical-driven health maintenance.
Perhaps more worrying from the standpoint of public health policy, is the gradual but ever-widening scope for encompassing more and more health-related issues into the public domain of health care and their labeling as disease entities.
The implications are of course huge—because once labeled as disease, these new ailments would require higher and higher health budgets and expenditure.
This disturbing trend has been viewed with much wariness and circumspection. It has also been termed by some as the medicalisation (or worse the commercialisation) of health, a dubious if less-than-reputable label.
Under this category would include: the menopause, the ageing male, baldness, and some say even sexual dysfunction including declining libido, female sexual arousal disorder and erectile dysfunction.
While good for business in their expansion in scope, we may be creating a new passion for hypochondria among our population out there. This is may be why so many amongst us have involved themselves with health maintenance schemes such as supplements, multivitamins and other gray areas of complementary health products such as growth hormone, androgens, DHEA, etc. Perhaps the Dorian Gray legacy has come home to roost with the medical fraternity which has lost its bearings and are running out of ethical business to tackle…
We have still to contend with new incurable diseases which have become pandemic such as the HIV/AIDS, and incurable others such as age-related malignancies, and we are still grappling with ancient ailments such as TB, malaria, hemorrhagic fevers and other infections.
Newly emerging viral infections have also stunned our recent complacency, when we begin to encroach into the animal-human boundaries of interaction and sanctuaries.
Our own Nipah epidemic, the bird flu and SARS seriously undermined our sense of personal safety, when they descended upon us with such a vengeance that practically quarantined entire geographical regions (the size of continents even!). We cannot yet escape the feeling that more challenges are in store for us, just lurking in the nooks and crannies of hitherto undisturbed undergrowth of animal-plant kingdoms.
Zoonotic transmission to humans will remain a serious if inevitable possibility. And we must continue to be vigilant, innovative and enterprising. Yet perhaps we might want to do more and take more care not to disturb the equanimity of our fragile ecosystem—by respecting and recognizing the limits of our ruthless development and unsustainable greed at the expense of nature.
Ironically however, mankind’s proclivity for self-destruction means that behind the clandestine walls of secret military intelligence, powers that be are still developing and holding huge caches of biological weapons, which could prove to be the end of us all, once these are intentionally or unintentionally deployed!
Viruses and bacteria have always been the most ancient and indestructible of life-forms—simple yet complex, miniscule yet parasitic, but most importantly they possess that innate trait of undiminished capacity to mutate, adapt, infect and propagate through the ages.
Perhaps they have always outlived all other extinctions from whence life began on Earth some three and a half billion years ago. Perhaps a new era of earth life will emerge devoid of humans, once we self-destruct…
Can we not allow ourselves then to fall back on less synthetic cures and panaceas?
Hence the return of organic and natural health salves and concoctions—we hope to avoid the use of the ‘poisons’ of new…
Yet unscientific as these may be, their word-of-mouth salesmanship continues to attract and beguile not just the uninitiated and illiterate, but many among the educated as well.
Doctors themselves are spellbound by either their touted benefits or their profit-potential…
Yet, we have to contend with ever-escalating patient empowerment, and socially-demanded health care scrutiny and audits for evidence-based practice.
The authorities and the media do not help much, and neither do our peers who are too busy eking out a living or too embroiled in new schemes for engaging a susceptible public.
But do we really care? Does it really matter? Who does the audits for benefits anyway?
Adjacent pharmacies, alternative healers and neighbouring sinsehs, homeopaths, naturopaths are thriving and our medical practice continues to face stiff competition.
But the business has to go on, some money has to be made one way or the other, better from someone who is well-versed about the benefits, the dangers or the potential harms or their lack thereof… Why bother at all?
Because so many of our patients have been reconsidering their own health options of late, which increasingly factor in alternative therapies and self-medicating, despite their many imponderables and question marks.
There is that growing distrust for all things science in this post-modern world, where the artificiality of life has become too much associated with perceived adverse outcomes, too out-of-touch with the senses, emotions and feelings.
Out-worldliness and new-found spirituality has remolded an ever-widening circle of new people (young and old) who want to make more sense of their own individual world and self-worth. They will not just tolerate the senseless cold reality out there.
Yet the fear of the unknown, and of ill health in our context, makes them adopt measures which are not totally in sync with their purported aspirations.
We all want to be as healthy as possible, and not suffer the consequences of ageing and other catastrophic ailments. So, many are willing to adopt dubious if totally useless supplements or alternative therapies which are if not harmful at least cater to their peace of mind that they are doing something positive for themselves.
Sadly quacks and charlatans, and indeed snake-oil purveyors have re-emerged as an amorphous group to challenge modern scientific health care.
To make matters worse, some of our own medically-trained doctors are immersing themselves into such contentious and poorly tested or unproved alternative or complementary therapies, many of which are based on bunkum and pseudoscientific gibberish.
It is a sad testimony of the fact that we as medical professionals are too diverse by nature, and too opinionated that we ourselves cannot be taught or guided to think along scientific principles.
Some of us are obviously willing to try the fringes of mainstream medicine and engage in wishful magical and senseless experimentation on our teeming clients out there.
We all worry about side effects and untoward consequences of new drugs, or of any medicine for that matter. Unfortunately such dreaded news have sporadically erected their ugly heads of disastrous public relations for the pharmaceutical and medical industry and which must unfortunately embroil us as doctors and health care providers!
The recent recalls of Lipobay and Vioxx have been particularly troubling and will remain sore points for us medical doctors to encourage long-term use of prophylactic medicines for chronic illness such as heart disease, hypertension and diabetes.
While it is true that hundreds of other drugs have been used for decades with great salvage of lives and improvement of survival and quality of life, all these become diminished in the harsh spotlight of such medicines being withdrawn due to harmful effects. “First, do no harm…”
Yet the medical establishment and some innovative physicians are now trying on newer and newer technologies in our quest to do the impossible—to cure and treat all and every illness and try achieve immortality, so to speak, for ourselves and for our patients or potential patients.
Many new research and studies are now testing new cures which add only marginally incremental benefits in the long-run, but in the name of progress we allow ourselves to be charmed by the munificence and beneficence of these types of ultra-modern care.
Polypharmacy has become the watch word for all cardiologists of which I am also guilty of—being in touch with the most current management guidelines and my peers, dictate that multiple drug regimens will enable my heart patients to live longer and more productive lives, but at costs which are so far only confined to dollars and cents.
Dare I venture to say that they will live longer and better? Based on our current information, this answer is still thankfully in the affirmative.
Less certain outcomes pertain to more aggressive interventions to correct the mechanical aspects of coronary artery disease.
With cardiac surgeons competing with the cardiologists for a bigger share of the limited pie, there is less than solid ground with which to objectively decide the “best choices” for the individual patient. It has now boiled down to patient’s preferred choice, and physician influence…
Often quicker results, shorter term gains and micro-surgical techniques will attract more adherents, despite more uncertain longer term results.
Then more recently, we have been encouraging more and more formerly normal (and by all purposes, “hearty and hale”) people to learn more and more about their health status and to try discover that potentially lurking ailment beneath the veneer of health.
Screening medical examinations have developed and grown staggeringly and has become expensive but profitable enterprises, although misguided when we factor in cost-effectiveness and possible harms.
From the humble beginnings which utilize the annual physical examination, simple blood screening tests, chest radiographs, rest ECGs, then to stress ECGs, gastrointestinal endoscopies, we have now progressed in certain urban locales to multiple-detector CT scanning.
Health scan or heart scan (or heart/health scam for the more cynical) are now being touted to make that unprecedented leap of faith to discover the miniscule chance that something might be wrong within the human anatomy.
Such mass CT health screening as these has never been endorsed by authorities world wide, but these days, they have been offered by enterprising medical groups (including doctors and business-partners) the world over.
The United States FDA in its statement recently noted that public health agencies and national medical and professional societies including the American College of Radiology, the American College of Cardiology / American Heart Association, the American Association of Physicists in Medicine, the Health Physics Society and the Agency for Healthcare Research and Quality's U.S. Preventive Services Task Force - do not recommend CT screening.
For heart scanning, the attraction is the purported simplicity and rapidity of the test and the captivating beauty of its photographic imagery of the heart and its vessels, as well as the 3-D rendering of the viscera in deceptive color-painted glory. Its not inconsiderable radiation exposure however, should be carefully considered.
Annual screening with a heart scan would expose any person to a radiation dose equivalent to more than 3.3 years of background radiation from cosmic and solar rays, or equivalent to having some 500 chest x-rays. A whole body scan would expose a person to an equivalent of more than 1000 chest x-rays of ionizing radiation (source: US FDA, 2004).
The potential dangers from such ionizing radiation cannot as yet be estimated. However, if annual whole body scanning examinations such as these are carried out, then the potential health hazards could be huge in the long term.
And there is that inescapable danger of self-referral which has dogged the medical profession since time immemorial.
In a recent Sept. 15 editorial titled “Who Owns Images of the Heart?” Dr. Alfred A. Bove, editor-in-chief of CardioSource for the American College of Cardiology (ACC) (an online journal and web page), noted that turf wars have broken out between the radiologists and cardiologists.
He noted that radiologists have voiced concerns in The New York Times, that imaging cost has become too high because this was driven by physicians’ self-referral patterns, particularly those of cardiologists.
According to Levin and others from Jefferson University Medical School, noninvasive diagnostic imaging rose 71% from 1993 to 2001, with cardiologists’ share of those Medicare dollars increasing almost twice as rapidly as that of radiologists. More important, payments to cardiologists in offices and private imaging centers grew at a rate of 240%.
Dr Bove however disputes the radiologists’ concern about self-referral claiming that this would be unlikely to occur as the ACC develops appropriateness criteria for utilization of imaging procedures.
However, Dr Levin (a radiologist) said it's ridiculous to believe that self-referral problems will disappear if cardiologists set guidelines for scanning. “That's a joke. They order scans for everyone who walks in the door,” he said.
Has medicine become too hot to handle? Should we in Malaysia engage in such obviously commercial enterprises? Clearly we cannot stem the onslaught of progress and we are seeing that glimmer of “cannot-beat them, join them” medical commercialism in Malaysia.
Can we regulate ourselves and our instinct to self-refer and if so, can we be objective that we are doing so for the public good?
Of course we all hate to lose out on new advances, new technology, but let’s not go overboard with too much enthusiasm as to lose our noble soul.
Consider too, a few years down the road when every medical establishment will get their own scanners and new technology, what then?
And where do we stand as doctors, as impartial healthcare providers whose main interest should be to provide for the patients’ interests, whilst not forgetting the public welfare?
Let’s not throw away the ethics baby with the bath water.
Let’s maintain our sense of proportion, and help preserve our trust in ourselves and the public’s trust in us.
Let’s keep some prudent paranoia about our basic instincts to see if we can still hold on to the candle in the dark.
Let’s contemplate our mission, our ethical moorings and search for that deep-seated flame of medical professionalism that must still be burning inside.
Perhaps dinosaurs like some of us who continually sing such an outdated song, are destined to become extinct.
But let’s see if we can preserve our professionalism for that little bit longer… and ask if we can be trusted to do the right thing, not in every instance, but at least we should try, and if we do fail, we do so by trying…
“I wake up tired, or more exactly without any appetite for life. My will to live diminishes as I get older, Did I ever have a great lust for life? I’m not sure, but I certainly used to have more energy. And expectations too. And you live so long as you have something to expect. It’s Saturday. I have time to dream and grieve.” ~ Ivan Klima, in No Saints or Angels, Granta Books, UK, 2001, p1.