Medical Ethics and Personal vs. Public Conscience: a Malaysian context

Medical Ethics and Personal vs. Public Conscience: a Malaysian context

By Dr David KL Quek, President, Malaysian Medical Association

 [published recently:

Quek DKL. Medical Ethics and Personal vs. Public Conscience: a Malaysian Context. 

World Med J. 2011; 57(1):2-4.]

Some time ago, New York Times columnist Professor Stanley Fish, (NY Times 12 April 2009)[i] wrote about “Conscience vs. Conscience”, where he discussed the conundrum about how people in general and physicians in particular, under different circumstances should or shouldn’t abide by their own conscience.

The contending issue was that physicians should not refuse treatment or procedures based on their own personal moral or religious grounds. Professor Fish argued that there is such a thing as a collective “public conscience” which should supersede that of one’s personal conscience and value systems, no matter how entrenched these may have been.

During the Bush administration, the culpable clause, called the Provider Refusal Rule, allows health care providers to refuse to participate in procedures they find objectionable for moral or religious reasons. The main bone of contention was of course regarding freedom to choose abortion, pro-choice, or conversely, pro-life.

In Fish’s article, he underscored an earlier statement by Mike Leavitt, Bush’s Secretary of Health and Human Services, who had said that, “Doctors and other health providers should not be forced to choose between good professional standing and violating their conscience.” The direction of the Bush doctrine was of course to urge the conservative right against unfettered abortion on demand, which continues to divide the American people.

Professor Fish reviewed the etymology of “conscience” as ascribed to English philosopher Thomas Hobbes. Here one of the earliest definitions of conscience, referred to those occasions “when two or more men know of one and the same fact . . . which is as much to know it together,” and where, violation of conscience meant that knowing together, men prefer their “secret thoughts” to what has been publicly established.

Fish acknowledged that Hobbes understood that many consider conscience to be the name of the private arbiter of right and wrong. But Hobbes regards this as a corrupted usage invented by those who wished to elevate “their own . . . opinions” to the status of reliable knowledge and try to do so by giving “their opinions . . . that reverenced name of Conscience.”

Hobbes’s main argument is that if one can prefer one’s own internal judgments to the judgments of authorized external bodies (legislatures, courts, professional associations), the result will be the undermining of public order and the substitution of personal whim for general decorums: “. . . because the Law is the public Conscience . . . in such diversity as there is of private Consciences, which are but private opinions, the Commonwealth must needs be distracted, and no man dare to obey the Sovereign Power farther than it shall seem good in his own eyes.”

Following his article, Fish was roundly criticized for being half-right in his interpretation of conflicting conscience, but intellectual disagreement continues to divide mostly implacable and partisan ethicists. Nancy Berlinger in an ensuing Hastings Center Report[ii] has this to say: ‘Stanley Fish… recognizes that defining “conscience” more loosely – as “moral intuition,” or those “secret thoughts”…  does not solve our contemporary problem. When medical professionals believe that they are being forced to do harm or are prevented from doing good, the ethical solution may not always be the conscience-clause remedy of stepping away from troubling situations.’

Where does this leave the medical professional when it comes to ethical underpinnings of doing what’s right or wrong? Would our personal conscience suffice? Or, should we subsume to the greater wisdom of our collective professional voice (e.g. national medical associations, professional bodies, world medical association, medical councils, etc.), which through the long arduous passage of time and historical experiences, would have honed a burnished if straitjacketed version of what’s generally accepted as “ethically and publicly correct”?

Be that as it may, does this mean that the medical professional would then have no need to rely on his own personal conscience and moral standing? No, but surely if these are diametrically opposed to the greater wisdom of peers, then one has to justify one’s personal convictions all the more!

Again, this cannot be taken out of context of the prevailing society and sociopolitical situation. This becomes extremely relevant in societies such as in Malaysia and other quasi-democratic nations, where governments tend to be paternalistic, even arrogant or worse.[iii] The instruments and institutions of power are often abused to forcefully interpret laws or even medical findings in a slanted manner, which severely test the mettle and autonomy of physicians under their charge.

In certain authoritative or political circumstances, the medical professional is called upon to exercise extreme judgement calls, which can be sorely tested by either threats from or fears of authority (e.g. police, superior officers, military, even political powers) or worse, direct or indirect ‘rewards’ for passive compliance!

The 1^st century AD Hindu code, Charaka Samhita[iv], exhorts doctors to “endeavour for the relief of patients with all thy heart and soul; thou shall not desert or injure thy patient for the sake of thy life or living”, which have been restated in many codes of professional conduct including our own. Yet, these are often pushed to the backburner, when conflicts of duties, arise.

Recently in Malaysia, public spats on medical testimonials and reports have arguably cast long shadows as to the so-called impartiality, ethics or professionalism of some of our medical colleagues.[v] Forensic pathologists are facing some intense scrutiny of late, due to questionable lapses, incoherent practices and perhaps even perceived selective memories, and slipshod standards of duty of care.[vi]

Other physicians making medical reports are also put under the microscope for their perceived biasness or slant of their reports, one way or the other, until the truthfulness of one vs. the other, appears difficult or impossible to discover![vii]

Such ambiguous if disingenuous medical findings or reports cast a dismal if disappointing view on our profession.[viii] While some of these appear coerced, some might conceivably be simply venal, just as if medical veracity can be made to sway according to the purchasing power of the most damning and powerful!

Physicians must be reminded that for that patient (deceased or detainee) under his/her charge, there is frequently no other person whose interests can be represented, except from the physician’s unbiased assessment…

Sadly some of these dubious practices place us at odds with the perceived wisdom and conventions of some greater external collective conscience. These conventions although seemingly unenforceable, have long been articulated by world authorities such as the World Medical Association and even the United Nations Human Rights Commission.

The UN High Commission for Human Rights Istanbul Protocol[ix] is categorical in stating that:

“Dilemmas arising from these dual obligations are particularly acute for health professionals working with the police, military, other security services or in the prison system. The interests of their employer and their non-medical colleagues may be in conflict with the best interests of the detainee patients. Such health professionals with dual obligations, owe a primary duty to the patient to promote that person’s best interests and a general duty to society to ensure that justice is done and violations of human rights prevented. Whatever the circumstances of their employment, all health professionals owe a fundamental duty to care for the people they are asked to examine or treat. They cannot be obliged by contractual or other considerations to compromise their professional independence. They must make an unbiased assessment of the patient’s health interests and act accordingly.”

Unfortunately, this protection by convention appears so remote to the lonely physician standing in the grips of perceived authoritarian powers, whose influence are imaginably all-powerful!

Seen in this context, society must exert its moral imperative of the public good on a universal basis, and demand the application of such universal conventions, to protect the hapless physician at the centre of such political or partisan storms, lest such pressure lead to further erosion of already debilitated institutions.

Similarly, the onus is on members of the medical profession to remain steadfast to the doctrine of public conscience and universal principles rather than personal ones, when carrying out our duties, including when making judgement or pronouncement on some of our possibly errant colleagues. Sectarian perceptions whether religious or political, clearly must take a back seat, and should not be allowed to colour our thinking or decision making.

Personal bias or experience or even conviction should yield to the more nuanced, perhaps more balanced decision based on strict interpretations of statutes, codes of professional conduct, and perhaps legal precedents.

The US Supreme Court[x] has ruled that when the personal imperatives of one’s religion or morality lead to actions in violation of generally applicable laws — laws not promulgated with the intention of affronting anyone’s conscience — the violations will not be allowed and will certainly not be celebrated; because: “To permit this would be to make the professed doctrines of religious belief superior to the law of the land, and in effect to permit every citizen to become a law unto himself.” Therefore, we must be quite clear to dissect conscionably our dilemma of which is the superior right.

Similarly, in the context of political or authoritarian pressure, especially where democratic institutions are weak, and where risk to the individual may seem likely, it behooves the professional to be reminded about the World Medical Association’s Declaration of Geneva[xi], which is a modern restatement of the Hippocratic values, as well as to be cognizant of UN Conventions such as the Istanbul Protocol. Doctors are reminded that the health of their patients is their primary consideration and that we must devote themselves to the service of humanity with conscience and dignity.

We must learn from and adhere to our historical memories, which are collectively acknowledged as “correct” and first and foremost for our patients’ interests. Certainly, in this context, every professional should not let religious, political or sectarian reasons from influencing our decision-making.

But does this mean that these are fixtures which cannot or should not be modified with the passage of time and perhaps move in tandem with the “fashion” or faddism of current perceptions or even societal movement or direction?

Clearly this will depend on the circumstances and the human aspects of all patient-physician interactions. Although ethics these days are not as immovable or as permanently cast in stone, societal views do evolve. Like sometimes shifting tides, ethical perceptions may very gradually ebb and flow, but often with the anchored moorings and underpinnings of moral public good and greater and greater foundation of universal values.

So changes may occur, but again these must be based on contextual interpretation which should be carefully justified so that the newer interpretation can withstand scrutiny and/or rigorous re-examination, by an increasingly knowledgeable public and also by even more discerning generations of similar professionals.

Thus, personal conscience and public conscience must be employed together to shape our moral compass when we are dealing with ethics and medical professionalism. It helps when we all undertake to reexamine our own values and learn more and more as to how these ethical dilemmas and questions are evolving in this day and age. We must not be cowed into a mindset of convenient way out or of callous expediency.[xii]

References:

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[i] Stanley Fish. Opinionator. Conscience vs. Conscience. The New York Times. The Opinion pages. 12 April, 2009. http://opinionator.blogs.nytimes.com/2009/04/12/conscience-vs-conscience/ (Accessed 26 Jan 2011)

[ii] Nancy Berlinger. Conscience: We’re Not Donne Yet. Bioethics Forum. The Hastings Center Report. 07 May 2009. http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=3404&blogid=140 (Accessed 26 Jan 2011)

[iii] David KL Quek. Unbiased treatment for all. Malaysiakini, March 23, 2010. http://myhealth-matters.blogspot.com/search?q=ethics+conscience (Accessed 26 Jan 2011)

[iv] Roy, P. Gupta, H. Charaka Samhita . A scientific synopsis. 2nd Ed., Indian National Science Academy, New Delhi, India, 1980.

[v] David KL Quek. Kugan’s Autopsy Findings & Inquiry: Unsettling Questions remain Malaysiakini 8 April 2009. http://myhealth-matters.blogspot.com/2009/04/kugans-autopsy-findings-inquiry.html (Accessed 26 Jan 2011)

[vi] David KL Quek. Ethics, medical confidentiality vs. political pressures. Malaysiakini July 31, 2008. http://dq-liberte.blogspot.com/2008/07/ethics-medical-confidentiality-vs.html (Accessed 26 Jan 2011)

[vii] Debra Chong. Teoh family disappointed with British pathologist’s report . Malaysian Insider 26 April 2010. http://www.themalaysianinsider.com/index.php/malaysia/61368-teoh-family-disappointed-with-british-pathologists-report (Accessed 26 January 2011)

[viii] David KL Quek. Physicians must be more vigilant. Malaysiakini 11 March 2009. http://myhealth-matters.blogspot.com/2009/03/doctors-must-be-vigilant-when-dealing.html (accessed 26 Jan 2011)

[ix] Istanbul Protocol. Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. OFFICE OF THE UNITED NATIONS HIGH COMMISSIONER FOR HUMAN RIGHTS. United Nations, Geneva, 1999. 
[x] Scalia, J., Opinion of the Court. SUPREME COURT OF THE UNITED STATES; 494 U.S. 872. Employment Division, Department of Human Resources of Oregon v. Smith. CERTIORARI TO THE SUPREME COURT OF OREGON No. 88-1213 Argued: Nov. 6, 1989; Decided: April 17, 1990

[xi] WMA Declaration of Geneva. Revised 173rd Council Session, Divonne-les-Bains, France, May 2006. http://www.wma.net/en/30publications/10policies/g1/index.html (Accessed 26 Jan 2011)

[xii] David KL Quek. A New Malaysia still possible. Malaysiakini, March 9, 2010. http://dq-liberte.blogspot.com/2010/03/malaysiakini-new-malaysia-still.html (accessed 26 Jan 2011)

Medicine—Reigniting our Passion…

Medicine—Reigniting our Passion…

Dr David KL Quek, drquek@gmail.com

“Where is the wisdom we have lost in knowledge?

Where is the knowledge we have lost in information?”

~ T.S. Eliot. The Rock, 1934

“Physicians combine two diverse tendencies in their daily functioning, a scientific mode of thinking and a clinical commitment to healing. The former requires us to be rigorous, dispassionate, objective, loath to reach conclusions until incontrovertible facts have been assembled. The clinical, or professional, component, on the other hand, compelled by the urgency to assuage suffering and to defend life, demands immediate action even in the absence of complete data." ~ Bernard Lown, M.D. in Prescription for Survival: A Doctor’s Journey to end Nuclear Madness. Berrett-Koehler Publishers, Inc., San Francisco, 2008, p.61.

Traditional roots of medicine demand some personal reflection…

Some thirty years of practising as a doctor can certainly embolden one to try and reflect upon a profession that so intimately inhabits one’s personal universe. Nevertheless, I do so with trepidation that I may have overstepped my expertise, my uncertain moral position in the august footsteps of so many unmatchable giants of our medical profession.

Yet, I have been impelled to do so, to try and set down my nebulous thoughts as to what and how the concept of the modern doctor is changing or taking shape, amidst the tremendous transformations and challenges that have swept the medical profession and health care scene.

Being a medical doctor is certainly one profession, which can become an all-consuming life and living itself—one learns to eat, drink, and breathe medicine.

Our thoughts and thought processes are submerged within the lingering echoes and ethos of a Hippocratic ancien regime: one of highly-structured codified dos and don’ts and exhortations of an intricately-crafted analytical process. Many are now lamenting the relevance of these methods and constraints, the seemingly outmoded sweeping codes, so enshrined within its antiquarian Aesculapian confines.

Nevertheless this singular system has continually defined and redefined itself, with modernizing inputs from our forefathers—all highly regarded stalwart champions of principled medical practices and professionalism. On the basis of the Hippocratic tradition, medical practice has been transformed increasingly into a more rigorous scientific system—one that is better evidence-based, with consistent veridical facts, and most importantly, one that is able to deliver reliable repeatable quality of care and cure outcomes.

No longer is the practice of medicine simply the handed down legacies of trusted wisdom and opinions of a few experienced if authoritative masters. Direct challenges to untested even if persistently accepted practices from long ago have helped democratize and expand the scientific reach of medicine into more solid bases of substantiation.

Science and art meld together in an intertwined universe of shifting and ratifying complexities, which ultimately give up its ghost in some form of a therapeutic modus operandi. At least, that is what appears to be the articulated goal of medicine—to comfort always, to heal sometimes, and hopefully never to cause harm: Primum non Nocere (First, do no harm).

Most importantly but often forgotten in the glitzy or fevered attempts at dealing with modern ailments and newly-medicalized disorders, we should remember that our patients are our raison d’étre. Medicine exists because there are patients out there who need or deserve our services, our care. The converse is not necessarily true, and may indeed not be to our patients’ benefit.

These days, it is possible to forget that oftentimes, tangential rather than exceptional discoveries create new demands for newer approaches which may have become too all-inclusive: our healthcare lattice is thrown far too wide and spread too thinly. So much so that lifestyle, ageing-related or other psychosocial aberrations have become incorporated within new designations as novel ailments.

Some have suggested that such ready ‘medicalisation’ may be too indiscriminate and inappropriate. Some have been promoted and perhaps may even have been invented by “Big Pharma”. Some of these disorders have become propagandized and marketed as “real” ailments, which need to be diagnosed, investigated, and yes, even treated aggressively.

Evolving evidence-based Medicine

From folkloric herbs, bone setting, stone cutting, etc. we have now entered into a new era of thrust for evidence-based medical practice, or at least that’s what has been loudly proclaimed of late.

Out of the ashes of historical anecdotes and passing down of learned experiences, accepted ‘truths’ have been systematically debunked when put to more rigorous testing and ratification. Many pearls of long-accepted wisdom have been crushed under the weight of new evidence, and in their places have arisen newer concepts of better-tested, better proven ideas. However, the reality is that medical practice is not all based on rigorous or dogmatic scientific facts. We still have so many incomplete answers or limited comprehension on countless ailments.

Complicating this is the fact that different ailments affect different patients differently: some more gently, while others more catastrophically and perhaps even fatally. Such is the inconsistency of occurrences which doctors have labelled as ‘idiosyncrasies’, i.e. chance events and effects, which affect individual patients in peculiar, unexpected and often inexplicable ways.

Unbeknownst to some of our frustrated patients out there (who wonder why we sometimes cannot be more definite or sure, or why some unexpected outcomes or complications continue to take place), doctors still don’t know quite enough, at least, not for each and every medical illness or variant. We still puzzle over why certain twists and turns occur despite the rigorous implementation of what’s considered proper treatment, which are guided by evidence and research. The human body still escapes total understanding and occasionally behaves erratically and outside the rigid boundaries of expectation.

Even the most brilliantly gifted or polymath amongst us, would shy away from presuming that they know everything. However, there are those who do perceive of themselves as ‘gods’, the know-all who can dispense largesse and treat without any qualms of uncertainty but with the dogmatic conviction of a cocksure pedant—the expert extraordinaire. But with the relentless onslaught of scientific evidence constantly permeating the information universe, it would certainly be foolhardy to be so presumptuous, leaving far too little for cautious error or acknowledgement of possible uncertainties.

Medicine’s self-correcting mechanisms may be slow, erratic and staggered…

By espousing a self-correcting mechanism based on scientific tenets, western-style allopathic medicine has been marching along relentlessly, almost always improving upon itself, whilst dumping wrong or inaccurate concepts, measures, or treatment modalities. Sometimes a long-discarded or long-forgotten concept is revitalized and rejuvenated as more discoveries prove its better consistency and veracity.

This flip-flopping of ideas and beliefs can be confusing to the layperson, who wonders why if medicine is a science, there is this shifting or changing of premises. How can some medical ‘facts’ suddenly be overthrown tomorrow by some newer discoveries, or newer ‘truths’? How can a drug, long prescribed for a certain indication, be suddenly hazardous for another condition, so that it has to be withdrawn?

This is especially so when news-breaking clinical studies show adverse outcomes much to the consternation and confusion of the research scientists who had predicted otherwise.

Just a few years ago, an arthritis pain-relieving drug Vioxx (refocoxib) was found to be associated with increased heart attack and stroke rates especially after prolonged use, and had to be withdrawn. But this later action was reluctantly foisted upon the company only after costly legal battles; Vioxx had earlier been approved for global use for several years. Thus, while Vioxx was very good at its narrowly-defined efficacy, it was unfortunately putting more people at risk of suffering and succumbing to seemingly unrelated cardiovascular disease. This covert but delayed safety issue was regrettably not uncovered soon enough, but was clearly not acceptable for treatment of non-life-threatening chronic disorders when there are safer alternatives available.

Another example relates to some changed surgical decision pathways. Why indeed have some long-established surgeries now been deemed unneeded, outdated and even passé? Yet at other times why have drastic, occasionally mutilating, surgeries to be emergently performed to save a tenuous life?

Gastric surgery comes to mind as a glaring example, when aggressive antibiotic-acid reduction medications have supplanted gastric resection for ulcer disease. A previously well-hidden bacterium (helicobacter pylori) is now established as the cause of most of stomach ulcers and even cancers. Yet, conversely some life-saving gastrectomies might still be necessary in severely bleeding and exsanguinating gastritis, when medical therapy fails.

Another controversial if more personally-decided surgery is that regarding the option for radical mastectomy or simple lumpectomy for breast cancer. Questions of staging and lymph gland involvement are not readily clear for many patients, who frequently opt for less mutilating if incomplete surgery. Then, there’s that question of whether every patient should have that expensive not-readily available PET-CT scan to determine if the cancer had spread beyond its usual boundaries…

The choice for complex angioplasties versus coronary bypass surgery for multi-vessel coronary artery disease is another point of contention, which sometimes border on personal patient-physician preference rather than hard scientific evidence. Such evidence bases unfortunately fluctuate in time-dependent verifiable specifics, which are sometimes dictated by contemporary changes or refinements in technique or device advances.

Thus, are there really any unfailing medical ‘truths’ out there? Perhaps there never will be. This is because modern medicine is often about evolving comprehension and continual scientific ratification of concepts and practices. Some of these may indeed be revolutionary and requiring paradigmatic change in mindset and orientation.

Best Fit Medicine ever changing, updating…

Modern medicine these days is constantly adopting what’s currently the best fit, the most appropriately cohesive model, to the best of our up-to-date understanding, as we dip our curious minds into the flowing river of advances and new knowledge. We can never really dip into the same river twice without its nourishing waters having moved along… but it is through this ever-changing experience that we can hope to harness the best that modern medical knowledge can offer.

Thus, we really cannot afford to simply sit back and be idly complacent while the inexorable advances of medical and scientific research and discoveries unravel with such accelerating paces—we have to update our knowledge base and skills all the time—hopefully on a lifelong journey of continuing professional development (previously known as continuing medical education), so clichéd, yet so much a desired mandate for today’s physicians.

The Internet, the World Wide Web and the explosive information expansion has not helped alleviate this dilemma of how to make practical sense of what’s good and what works. Because, for each of our individual patients—ultimately and in a very curiously uneconomic way—being a doctor usually means dealing with that one patient and his/her problem, piecemeal.

[Only in epidemics or potentially public health calamities e.g. avian influenza or SARS (severe acute respiratory syndrome) and the current A(H1N1) pandemic, do we engage our autocratic prerogative, which collectively and without exception, corral our resources and authorise therapeutic or prophylactic measures on a designated at risk or exposed population.]

Medicine can and does consume our souls if we let it, and it can and probably should dictate a mystical ethical code of conduct which should exhort us to rise way above all others, in our dealings with humanity and with our patients in particular.

“Deprofessionalization”

However, these days, in some areas, the practice of medicine appears to have been lost in translation. Many doctors are disenchanted with the so-called practice as usual—many are now feeling a greater and greater sense of loss of autonomy and a growing sense of ‘deprofessionalization’, where insurers, third party payers, and managed care organisations are dictating how they practice, who they can treat and when, and how much can be reimbursed or not at all.

In 2006, the roll-out of the private healthcare facilities and services regulations for Malaysian doctors, added more fuel to the firestorm of practice issues which seem to overwhelm the wretched medical practitioner!

So what do some doctors do? They have become angry and feel quite betrayed. Practising clinical medicine had become a grinding drudge for some: mounting paper-work, senseless work-flow charts and reports, with ‘ludicrous’ micromanaging oversights, which seem excessive and demoralizing. Many had described these harsh regulatory articles and especially the prescribed punishments as criminalizing and degrading.

Such laws seem to imply that doctors who had been practising autonomously all along with little intrusion or mishaps, have become potential felons (in one fell swoop of the enactment of the Regulations by the Minister of Health) and that if some of these practice issues are not modified or adhered to, they are to be regarded as criminals with stiff fines and even jail time! Some had indignantly expressed their intentions to quit practising medicine altogether, others are defiantly recalcitrant.

Some doctors have become so unhappy, angst-driven and frustrated that they have lost their zeal and passion for their medical practice—the former patient-doctor relationship have become sundered with suspicion and regulatory mess-up, which trespass into their sense of justice and professionalism.

Dabbling in Fringe Therapies…

Quite a number of the more enterprising have moved laterally to fringe margins of allied health disciplines. Dabbling or even full-time engagement with beauty or aesthetic health care appears simpler, i.e. away from the more demanding and challenging clinical practice of general or family practice.

Some also have moved into the even more lucrative anti-ageing or drug-dependency programmes, which once again seem to be more rewarding and satisfying, even if less taxing mentally or intellectually!

Others indulge in fringe, obscure if esoteric “techno-babble” pseudo-medical practices (e.g. electro-diagnostic analysis for general health promotion, live blood analysis as screening procedure for possible medical ailments, whole body aura analysis, colonic washout therapy, qi gong for all ailments, ozone therapy, chelation therapy, etc.) which creates a semblance of ‘scientism’ and rational modernity, but which are at best hocus-pocus quackery at its most sophisticated.

Some are embracing complementary alternative medicine, which appears to be increasingly popular and in sync with the more suggestible public out there, despite the fact that their scientific bases are so much less proved, or none at all.

Erosion of youthful dreams, reigniting compassion and vocation…

When as a young teenager I dreamt of becoming a doctor, my fledgling youthful hopes and ambitions now seem so wonderfully fervid and overpowering. Back then, the starry-eyed passion and awe seamlessly suffused through my senses and waking moments and enveloped my entire psyche and persona. Then too, my concept of altruistic high-mindedness appeared to overwhelm all other considerations.

How far-away these thoughts and feelings now sometimes appear, how nebulous, how child-like and oh, how evanescent… That naïveté, which I have so blurry-eyed conceptualised, now seems so distant a memory, sometimes… Hard-nosed reality these days shatters our childlike dreams of simplicity, equanimity.

It is against this backdrop, that we should address the issue of where our medical profession is heading. With the onslaught of rising commercialism, market-driven personal consumerism, and greater patient autonomy, it is becoming increasingly hard for the medical professional to practice as a doctor.

To be that quintessential compassionate, empathetic health care provider so to speak, can be extremely demanding and challenging, what with the inherent diagnostic/therapeutic uncertainties, the spectre of fees and costs, medico-legal and other pecuniary considerations impinging upon the doctor’s and the patient’s consciousness.

During the coming two years of my presidency I wish to address some of these issues through the prism of a physician who passionately believes that medical doctors can make a difference, that health care can and must be engaged to make it as human and humane as possible, while staving off the onslaughts of rising commercialism, medicalisation, political and/or third-party oversight and progressive loss of our physician autonomy.

I hope to inspire a new look into the possible art of healing which appears to have taken a backseat with the rising tide of challenges and the onslaught of de-motivating practice issues. We must learn to reclaim our sense of purpose, our vocational goal, and reassert our meaningful role in modern society.

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