“I will follow that method of treatment which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. Things I may see or hear in the course of the treatment or even outside of treatment regarding the life of human beings, things which one should never divulge outside, I will keep to myself holding such things unutterable.”
— Hippocratic Oath (400 B.C.)
These lines have served as the ethical guide to medical practitioners for centuries. Traditionally, medical profession has been considered a noble and honorable profession. Honesty, trustworthiness, integrity, discernment, compassion, kindness and conscientiousness are the virtues applicable to medical practitioners. Many physicians became doctors because they loved personal relationships with fellow human beings who were suffering and needed help. In this connection, a medical practitioner is expected to follow four principles of biomedical ethics: beneficence (doing good), nonmaleficence (avoid harm), autonomy (of the patients) and justice while caring for the patients.
The patient-physician relationship is a crucial underpinning of all societies, second only in importance to family relationships. Patient-physician relationship is a contract involving the exchange of money and services. However, the traditional model of doctor-patient relationship was paternalistic (doctor centered) driven by the fact that doctors were expert professionals who would decide the best course for their patients, who wanted to get well and who were expected to cooperate and comply with the doctor. But doctors in the 21st century are encouraged to work in partnership with their patients, informing, guiding, advising, and helping them make appropriate choices about how to deal with their illness. This is a shared and informed decision making model where the two parties reach a ‘concordance’ about the best course of action. It shows greater respect for patient autonomy, enables patients to take greater responsibility for their own health and has been shown to result in positive health outcomes.
Empowering patients with appropriate knowledge to participate with doctors in a collaborative, constructive partnership that leads to quality healthcare at a reasonable cost is in the duty of the 21st century doctors. Today’s patients are not simply recipients of care or subjects of research but active, informed individuals who wish to exert greater control over their own care: “nothing about me without me.” This, though, does not mean doctors pass too much responsibility onto patients just to shift the blame, should things go wrong. What is needed is a reiteration of the fiduciary obligation of the physician and the central role of the patient in the relationship.
Changes in biomedical science, health policy, and medical education have led to new ways of thinking about professionals, patients, and encounters between them. In the last decade, rapid changes in the healthcare delivery system and socio-political climate have resulted in considerable strain on patient-physician relationship. The increased awareness among people regarding their fundamental rights has brought the medical profession under sustained scrutiny of both the public and the courts. Good intentions do not guarantee good outcomes; negative results ensue from even the best care. After all, doctors are human beings too.
There are two kinds of medical negligence. First, doctors may be negligent and commit a mistake, and second, the support staff may be careless. These acts of negligence may give rise to much bigger problems. Now a medical graduate not only has ethical duties as dictated by Hippocratic Oath, but also legal accountability towards the patient and the society. The US, for one, is facing a “malpractice crisis”. According to Tom Baker, Professor of Law at the University of Pennsylvania, “We
[Americans] have an epidemic of medical malpractice, not of malpractice lawsuits.” Medical negligence lawsuits serve as redress mechanisms to compensate patients who have suffered for no fault of their own and to protect people from unacceptable practice.
SITUATION IN NEPAL
The situation in Nepal is challenging. Even the poor people have to pay for medical care through their own pockets, but only under 50 percent healthcare facilities is provided by government-supported health institutions. Hence it sometimes seems that only the rich patients have the right to live. Doctors are overworked in private institutions, without any regard for ILO recommended of 40 hours of practice per week. While, not many medico-legal cases have been taken to court in Nepal so far, compensation for alleged negligence is claimed through protests and demonstrations, and many times health professionals have been manhandled and physical facilities damaged. While the concept of autonomy, informed consent, concordance and primacy of the patient prevails in rest of the world, many Nepali patients and their relatives bring in distant relatives or local leaders to discuss primary management issues with their doctors. When faced with chronic diseases, our patients resort to two ways: “doctor shopping” and traditional and/or ayervedic medications.
Congested emergencies, crowded outpatient clinics (OPDs), inadequate ward and ICU beds, understaffed wards, flooded laboratory and imaging services, improper information system for patients, infrequent specialty clinics in hospitals, inadequate supply of emergency drugs in hospitals, questionable sanitary conditions, underpaid hospital staffs, etc have all conspired against quality service and directly and indirectly resulted in damages, leading to patient and public dissatisfaction. The quality control mechanism of investigative facilities like laboratories and medicines (storage and transport) is almost nonexistent.
Occasional mishaps result from illiterate patients experimenting with medicines or having been given wrong medicines by inadequately regulated dispensaries. On the other end, because of the changing sociopolitical condition, there is a growing mistrust of medical professionals and at times inappropriate expectations from medical services. There is a trend of asking for compensation through demonstrations in every unfavorable treatment outcome, irrespective of the prima facie evidence of absence of medical negligence.
Only public awareness regarding limitation of medical science, improved health care delivery system and improved communication skills of healthcare providers can fulfill the “unchanging goals of medicine” of helping and caring for the sick and disabled people with respect and dignity and reestablishing the ageless patient-physician relationship. The balance would be a responsible doctor and understanding patient guided and monitored by independent and able judiciary. Nepal Medical Council (NMC), the apex body with the responsibility of guiding and regulating medical practices in the country, also needs to play a greater role to ensure that doctors are providing ethical and quality services to the people. At the same time, the rights of the professionals should also be adequately protected.