A Book Review: “MEDICAL ETHICS, ETIQUETTE AND LAW”

A Book Review:
“MEDICAL ETHICS, ETIQUETTE AND LAW”
written by Dato Dr Abdul Hamid Abdul Kadir

This book “Medical Ethics, Etiquette and Law”[1] appears at first glance to be a primer for the medical student and graduate, but perhaps, may be appropriate even for the doctor who wishes to refresh and renew his/her basics in medical professionalism.

It harks back to the times of good ‘old-fashioned’ clinical teaching—perhaps, as a judicious reminder of a lost art. In our rush to produce annually, the thousands of doctors from our medical colleges, many are now feeling that the art of practicing medicine has been lost in the translation. With rising numbers, come increasing complaints and criticisms about unprepared, uncouth even unethical, uncaring, stressed-out medical graduates. [2]

Some academicians and senior consultants have decried that medical ethics and professional etiquette seemed to have taken a backseat in our modern day medical teaching institutions. [3] Even more remote from the minds of many graduating doctors is the proper understanding about the ethical moorings and legal aspects of modern medical practice.

It seems we are constantly enthralled and overwhelmed by the stupendous enormity of scientific advances and factual knowledge. We enthuse excitedly about newfangled ideas and theories, and dabble in many less-than-evidence-based therapies.[2] Yet, we frequently neglect or pass over what truly matters—the clinical encounter with our patients.

In our mundane day-to-day clinical encounters we often pay too little attention, and sometimes unwittingly short-shrift our patients with our callous disregard, or unintended inattention. In some instances this lack of communication or miscommunication has resulted in untoward responses which contribute to so much angst and chagrin to those involved. [4]

We are sometimes baffled by the competing demands of apposite medical practices, personal biases, moral hazard (i.e. conflict of interest decision making) and the pervasive market-driven consumerism, so much so that we have subsumed our nobler instincts, and have lost our humane compassionate touch. Professor Bernard Lown, Nobel Peace laureate and outstanding cardiologist, has described this in an aptly titled book “The Lost Art of Healing.” [5]

The author Dato Dr Abdul Hamid has been an exemplary medical professional par excellence. He cuts a distinguished career spanning more than 40 years, with stints in the Malaysian Military as a full Colonel, when he was seconded to Universiti Kebangsaan Malaysia as department head and professor of orthopedic surgery until retirement, when he then ventured into private practice.

Dr Abdul Hamid has spent significant portions of his entire professional life fully aware of the niceties and the challenges of clinical medical practice, medical ethics and professionalism, as these evolve through the decades.

But it is by being fully engaged in the profession, its regulations and laws, that Dr Hamid has excelled himself; and this shows out prominently in his writing, and in this book.

Perhaps, the disciplined military experience and mindset has influenced the way Dr Hamid views the practice of medicine. Perhaps, that is why those who know Dr Hamid can attest to his very austere demeanour and his almost unshakable strength of character as well as his sometimes seemingly immovable observance to strict interpretation of ethics—the near-inflexible interpretation of right and wrong with scant leeway for errors of judgement.

But perhaps, this is how morals, ethics and etiquette should be perceived and practiced, as we march along in our contemporary universe of increasing moral relativism! Perhaps, our varying shades of grey in viewing through too many relativistic lenses have become too distorted from the newfound gravitational pulls of too many pseudo-viewpoints. [6]

Thus, we have become inured into subconsciously respecting too many false values and rights. Many are tempted to tread expedient rather than rightful paths. Ultimately our greying vision reflects the murky lack of courage to defend greater universal values. Should all traditional values and practices give way to modernistic ‘politically-correct’ interpretations just to stay current and fashionable? [7] Many would argue otherwise, and Dr Hamid has not shied away from saying so.

However, this is not to say that Dr Hamid is self-righteous, but that Dr Hamid has been consistently and morally courageous to stay his conscience. Dr Hamid is an unapologetic champion toward a very rightful approach to life and living—an approach most of us would be too timorous or find too challenging to adhere to, every time. Indeed, these very exacting tenets of living as a principled medical practitioner can be very hard acts to follow. [8]

Yet, there are poignant moments when his humane leniency shine through with a penetrating understanding of human nature that can only come from involved experience. I believe it is this luminous passion of Dr Hamid that makes him want to share his vision of what should still remain a core part of the medical profession—good solid values of medical ethics and etiquette, well-buttressed by a confident knowledge of legal boundaries!

Be that as it may, Dr Hamid has been the singular professional moral compass to which many peers now look up to for guidance. Perhaps that would explain how as a medical professional, Dr Hamid has been elected by his peers over the past 20-odd years to the MMC—a regulatory authority to safeguard and guide doctors on how they should ethically interact with their patients, with compassion, propriety and safety.

Since 1983, Dr Hamid has been involved with the Malaysian Medical Council, without a break—a truly remarkable achievement and a professional continuity of some 25 years. This places him in an enviable position to experience, witness, influence, as well as to perhaps, help bring about the changes and development of good clinical practice and medical ethics standards through almost a generation. [9]

Indeed, such is his moral authority that he has been appointed to chair the MMC ethics committee, as well as to other respected expert committees to oversee and arbitrate on many professional issues.

But Dr Hamid’s experience is not parochially wrought in a vacuum, but from real clinical practice out there, from the converging standpoints of a practicing doctor, a teacher and a long-serving regulator. In the interim, Dr Hamid had been presidents of the MMA, ASPMP and Council member of the Academy of Medicine, and thus he understands the multifarious leanings of different professional medical groups and vested interests.

Notwithstanding these dissimilar tuggings of disparate interest groups, this wealth of experience has not diluted the fervour of his enthusiasm to maintain that some things cannot be changed just because of the whims of time, caprice and fashion.

For Dr Hamid, and I believe, for a growing number of us mere mortals, medical ethics and professionalism remains the bulwark through which the medical profession must find some anchorage. Most relevantly his avid espousal of very strict adherence to strong moral and ethical standards has always put him at the forefront of professional issues which affect the doctor.

With his almost encyclopaedic knowledge of the Medical Act and its regulations and his uncanny ability to parse through difficult texts and legalese, Dr Hamid has always been approached to distil for many groups in the medical profession, the simple interpretation of basics from the abstruse intricacies of confusing laws and regulations. [10]

Dr Hamid is thus, keenly aware that medical professionalism, ethics and standards can and should be disseminated, taught and inculcated as widely as possible. Hence, I believe the gestation and fruition of this book (over several thought-provoking years!) for the medical profession—one that should guide doctors in an authoritative yet easily digestible manner.

This 138-page book is a crisp and succinct exhortation to the clinician—whether a budding house officer or a seasoned practitioner—to be more humane and compassionate. Above all the doctor is taken on a ride through many solicitous snippets and nuggets of practical issues which he or she can encounter in daily clinical work.

Clear thoughtful discussions abound in the pages, on how to take a good history, perform a thorough physical examination, while paying close attention to patients’ anxieties and sensitivities. Communication skills are woven comprehensively into a story-like discourse, to help the doctor avoid medico-ethical challenges and/or medicolegal suits.

Discussions on how much information to disclose, how to take comprehensive notes and make accurate records, how to transfer care, debating on the need to refer especially when our individual professional skills are limited, how to avoid pitfalls of consent taking, and what to do when adverse unexpected events occur, are discussed sensitively, with attention on how to avoid or lessen their impact.

The how and the need to write appropriately-detailed medical notes and legible prescriptions, record keeping, patient confidentiality is also well-detailed. Proper above-board patient-doctor relationships, careful attention to the use of chaperone, are also exhorted so as to forestall accusations of impropriety.

Cordial relationships and professional courtesies with colleagues are also encouraged with particular attention to avoid criticising (even if inadvertently) a fellow practitioner, as these often form the nidus for complaints and dissatisfaction by patients.

Report writing, practice issues, information dissemination, and pertinent ethics issues such as sick certification, locum tenens employment, non-therapeutic abortions, clinical trials and research issues are also briefly touched upon.

The latter part of the book discusses negligence, disciplinary matters and the various medical acts including registration and licensing issues, medicolegal issues (briefly shifting from the Bolam test to the Bolitho modification and latterly to the Rogers vs Whitaker standard) and the role and duties of the MMC.[10]

The last 16 pages are devoted to the Oaths taken by the various medical schools as well as summaries on some international medical codes such as: the declaration of Tokyo against medical involvement in torture; Nuremberg code and principles for wartime conduct for doctors; the Helsinki and Oslo declarations on biomedical research and abortion issues.

Together these overarching themes serve to bolster the ethical framework from which our medical profession anchors. This book represents a lucid extension of the MMC’s ‘Good Clinical Practice’ guidelines—which every medical practitioner should familiarize him/herself with—and, which is readily available from the MMC. [11]

Is this book useful? Definitely. The short but subtitled topics make for easy references. Therefore, if a practitioner wishes to check on a particular aspect of medical practice for which he is unsure as to the etiquette or proper ethics, this can easily be located and read on its own.

Thus, on a doctor’s book shelf, this can be a ready guide for day-to-day clinical reminders and reference, to be quickly retrieved by topics or by chapters.

Of course, it would be good to give this book a complete read once over—I did, and it took just over three thoughtful hours. But these are hours of refreshing reminiscences of how the best of caring, compassionate and ethically guided medical practice can be carried out—great practical tips and pointers on finding a greater balance of what is good and heartening in medicine.

Are there any deficiencies? Not really, because this book does not pretend to be a comprehensive treatise on all things ethical and legal—thus, its references and index are relatively sparse. It should thus serve as an excellent primer, except for the academically-inclined, for whom this might be a drawback. But it is a highly accessible book which distils all the practical wisdom from decades of clinical and regulatory experience, and deeply ingrained moral confidence.

The etiquette aspects so seamlessly embedded within the text may be a personal statement on what feels or sounds right within the context of an ethnically-plural society like ours. In some areas it is possible to disagree with the recommendations, which may bias toward more caution and rectitude than contemporary universally-accepted practices.

However, norms of etiquette are often societally determined, and would vary any way from society to society, country to country even. Be that as it may, as a safeguard against misunderstanding or breaching sensitivities, these exhortations on proper etiquette would, on balance, be considered prudent and ‘right’ in our Malaysian context.[11]

I would have preferred more anecdotes and practical discussions on hypothetical or learning cases which can then highlight the ethical and practice dilemmas a little bit more cogently and concretely. But this might in turn make the book a lot less readable and more unwieldy. Those who want a more academic and legalistic approach in this genre should consider the recently published “Medicine, Patients and the Law” (Penguin Books, 3rd edition, 2003, 560pp) by Law Professor Margaret Brazier of Manchester University.[12]

Finally, Dr Hamid’s book is current, authoritative and comprehensive enough to be read by all, not just once but even again and again, as it serves to remind us of so many experiential clinical issues which have been so fluidly woven into the fabric of this short treatise. I would wholeheartedly recommend that this book be read as a timely refresher by all medical practitioners, and perhaps also by those who aspire to join our ranks—the medical students.

For the lay person, this book may help to empower the would-be patient to know how and what a doctor can and maybe should practice medicine, perhaps as good as it gets. He or she might also better understand that the intricacies of medicine can be more complex than his/her accustomed expectations. [13]

Perhaps the would-be patient can even better recognize how intricate the medical encounter can be, but also increase his/her knowledge as to what his/her responsibilities and rights are. I believe knowledge always empowers, thus both parties can benefit enormously.

What about this book for the legal professional interested in Medical Law? This might be more difficult as the scope of legal details discussed in this book is rather limited. However, the interested lawyer can perhaps come to a greater grasp as to the multifaceted aspects of the medical encounter and its inherent complexities.

Perhaps, reading this book might also help them understand that litigious challenge is not always the best approach to address every patient-doctor conflict or contention of unfair, incompetent, unethical or negligent practice.

This book might reasonably raise the bar of ethical medical practice as well as help reduce the risk of medico-legal complaints for the modern doctor. Thus, this book can only succeed.

Reviewed by
Dr David KL Quek, FRCP FAMM FACC
28 Feb 2008

References:
1. Abdul Hamid Abdul Kadir. Medical Ethics, Etiquette and Law. University of Malaya Press, Kuala Lumpur, 2008
2. Merican MI. Is Medical Ethics and Professionalism at the Crossroads? Berita Academi, Dec 2007, pp3-7.
3. Quek DKL. Commercialisation in Medical Education—Where do Ethics come in? Paper presented at the Academy of Medicine of Malaysia National Ethics Seminar, December 1, 2007, at IHM, Bangsar, Kuala Lumpur.
4. Quek DKL. Is the Hippocratic Tradition still Relevant in Today’s Medical Practice? Berita MMA, Jan 1999, pp7-8
5. Lown B. The Lost Art of Healing. Ballantine Books, New York, 1999
6. Quek DKL. Ethical Concerns for Challenging Times. Berita MMA, May 1998, pp7-9
7. Pellegrino E. Doctors and Ethics, Morals and Manuals. Ann Intern Med 1998; 128:569-71
8. Rebecca Rosen, Steve Dewar. On Being A Doctor: Redefining medical professionalism for better patient care. King’s Fund, London, 2004
9. Abdul Hamid Abdul Kadir (Editor-Chair of Ethics Committee) Malaysian Medical Council. Guidelines of the Malaysian Medical Council, MMC-MOH, 2006
10. Abdul Hamid Abdul Kadir. Implications of Judicial Decisions on Medical Practice. Paper presented at ASPMP Medico-Legal Seminar, Pantai Medical Centre, Bangsar, Kuala Lumpur, April 1, 2007
11. Malaysian Medical Council. Good Medical Practice, Malaysia, 2001
12. Brazier M. Medicine, Patients and the Law. 3rd edition. Penguin Books, London, 2003
13. Puteri Nemie Jahn Kassim. Medical Negligence Law in Malaysia. International Law Book Services. Kuala Lumpur, 2003