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

Physician Apology, Saying it Sooner than Later

(see also myhealth-matters.blogspot.com/)

Recently a New York Times article ‘Doctors say "I'm Sorry" before "See you in Court"’ and a follow-up editorial ‘Doctors Who Say They're Sorry’ addressed the uncomfortable issue of medical errors, especially those associated with having caused harm to patients.

For most practising medical practitioners out there, medical errors are considered a near-taboo subject: one, which is best left behind the radar screens of scrutiny.

Yet we are aware that medical errors, especially those which are inadvertent or which result from unexpected patient/individual reactions or peculiarities, do happen, albeit not too frequently.

Being honest and direct with the patients involved can, safely diffuse many of these potential patient-relative complaints. Careful and candid explanation as to why these had happened and why they should not have, and that they would not be allowed to recur, will also help lower the temperature of annoyance and anger.

Most importantly, these types of errors should be treated as high priority and with empathetic sensitivity. Affected patients must be given every avenue to resolve or lessen the harm with the least incurring of pain, suffering or costs.

Of course, medical centres and hospitals must work together with doctors to address these so that cost sharing or waiver/compensation can be implemented expediently and efficiently. The patient should leave the facility satisfied that all that could have been done had been done.

More egregious are those errors due to diagnostic inaccuracy or therapeutic misadventure, incompetency or careless negligence. These are often deviously obfuscated, with blame deflected, or simply denied a full hearing or explanation to the harmed patients.

It is this group which when finally exposed, that oftentimes cause much anger and demand for compensation, or even calls to reprimand or to punish the erring doctor or facility. Hence, the resultant litigation process which every doctor dreads.

But, admitting to medical mistakes is easier said than done. Besides, in most medical cultures, it is not permissible or safe to do so. Yet, we know that more can and should be done.

Although some 10 years ago, when Lucian Leape's group from the Institute of Medicine reported that as many as 98,000 patients died as a result of medical errors in the United States ("To Err is Human")—many are adamant that this was exaggerated. Many still denied the actual enormity of the problem.

Then some time in the early 2000s, when the Consumer Association of Penang (CAP) president, SM Idris alluded to a similar state of unrecognised medical errors in Malaysia, as the then editor of the Berita MMA, I objected quite vehemently that to extrapolate based on the experience in the US was wrong and unacceptable.

Then, I had called instead for more in-depth study and urge our health community to research this by gathering more accurate data, so that we can get a clearer picture as to the scale and the scope of this serious problem. I also called for pre-emptive attention to detail and a systemic overhaul of procedures and processes to help reduce these possible errors from taking place.

Perhaps CAP's statement to the press was too artless and seemed to denigrate the overall goodness of the medical care experience that I had felt duty-bound to defend.

As an MMC councillor, however, I have had the privilege of listening to increasing number of complaints brought to the attention of the Malaysian Medical Council (MMC).

Most of these complaints are about unexpected adverse outcomes resulting from some medical therapeutic choices or decisions, which have gone awry, and/or unhappiness with the patient-doctor communication, or implied physician dishonesty.

Many of these MMC complaints are however, not ethical in nature and does not impute serious professional misconduct.

This is not to say that there have not been medical errors or misadventures having taken place, but that the MMC is not the board or forum for resolving disputes related to negligence or incompetence, unless there is a recurrent pattern of egregious conduct, which can endanger other patients. Unfortunately many among the public has mistaken the latter as the role of the MMC.

Quite often, disgruntled patients or their relatives complain of inadequate information provided to them, some even claim that none were offered at all. At other instances, when untoward bad outcomes result, not enough information or explanations were given. Too many delaying tactics or perceived deflection or excuses to very legitimate queries, often create unresolved feelings that the doctor and the hospital are hiding something.

It is this need to have closure and/or meaning that many aggrieved parties seek out the MMC or worse the courts to prove medical negligence, and ultimately seek retribution and recompense.

Of course, there are many lawyers out there who are quite ready for such pro bono work to litigate against such incompetent doctors or hospitals, and so the problem escalates.

Thus, many medical centres and doctor groups have begun experimenting with the new deal of becoming more forthcoming, and saying sorry first and early too.

Some 30 states in the US have enacted laws to protect the admissibility of such apology-related disclosure from medical malpractice challenges. And it appears that it is working. In some medical centres, early resolution with smaller compensation claims have already resulted, with some medicolegal costs falling by as much as two-thirds!

Thus perhaps for Malaysians too, this might be a way forward. Saying 'Sorry' and admitting candidly a medical error should not be taken as license to litigate, but as trying to resolve a bad situation from becoming worse.

Still, offering an apology to patients and their relatives is not a definite or necessarily positive reaction: some aggrieved parties would still doubt the sincerity or genuineness of the apology, and cynically view these as attempts to underplay the severity of the mishap, and a business tactic to secure patients/relatives into accepting a bad outcome.

A discussion with a renowned dispute resolution advocate, Dr R. Veerapan, suggests that genuine apologising “can be difficult for doctors who have been trained in a system where admitting error has the odour of moral failure.”

“'Apology' by healthcare professionals has wide ranging implications and it is very important for potential 'apologizers' to have a very clear understanding about what these may be.

“Individual institutional policies and procedures should be defined. Doctors should know for sure what the policy of their medical indemnifier is regarding apology.

“And of course there is the fine but critical difference between expressing regret and empathy for a poor outcome, and actually apologizing for making a medical mistake of some form. Not easy, apologising! Yet so important under carefully understood conditions!” adds Dr Veerapan.

I agree that apologies are such difficult and scary animals for most of us doctors because it implies a ‘moral failure’ on our part. More than that, it also exposes our lesser than perfect image that we have acculturated into our profession.

Perhaps we have to work towards a better modus operandi to make medical apologies more systematic and acceptable—while ensuring that legal barriers are reduced if not eliminated.

Dr Veerapan suggests that “one of the obstacles besides the medical invincibility factor is inherent in the DNA of Malaysian private practice. And that is the way we are pitched in indirect financial competition with other medical practitioners. This is the undefined factor that in all likelihood contributes to the reluctance to be forthright in a variety of professional relationships in the medical or surgical field; and not just with patients and their families.”

Such personal and professional dynamics aside, it is perhaps time to move forwards. Saying sorry appears to be a way forward to help lessen the adversarial approach that seems to stifle the medical error-negligence debate.

There must be mechanisms (perhaps legislative?) to protect such apology and disclosure, and perhaps we should also enact laws to ensure that admissibility of such information is protected from medical malpractice claims.

Another approach is through a wider judicial-led Mediation process, which has already been put in place in Singapore. At one MMC meeting in mid-May, Dr Thurairatnam, (a past-president of the Malaysian Dental Association and Dental Council member) presented a short lecture on how this may be a useful alternative dispute resolution process—the MOH is considering some way to explore this option further.

"Sorry seems to be the hardest word," so sang Elton John, but perhaps we as doctors can learn to say so earlier, sooner than later, and be ready to help our patients resolve better as a result, when medical care goes wrong.

Apology is a vital component in the healing process of early intervention when conflict escalates after an adverse medical event. We must all learn to cope better with and mitigate against these increasingly challenging aspects of modern medical practice. Humbling ourselves by being genuinely sorry and saying so, rather than defensively obscuring and/or excusing unpleasant and unexpected adverse outcomes is the way forward.

(This is an expanded version of my earlier blog which is to be published in the Newsletter of the Malaysian Medical Council, July-August 2008)