Teaching Medical Ethics in India

During the four weeks I've just spent in India (I'm at the Amsterdam airport now, on my way home) I asked two questions about ethics and ethics education: 1) Can the field of medical ethics, which is so well established in the west, contribute to improving health in India? 2) Insofar as the answer is yes - how?

Medical ethics is not well developed as an academic field in India. To the best of my knowledge there are no medical school departments of ethics. Minimal curricular hours are devoted to the subject.

I believe that ethics education can make important contributions to health care systems and ultimately to health itself. But I formed this view in the U.S. In India I challenged myself with my favorite question - "so what?" So what that ethics education in India is rudimentary? What difference could more attention to ethics education make in a country with more than a billion people including a rural and urban population barely living at a subsistance level that is larger than the entire U.S.?

I was able to have a series of meetings with people who were generous with their time and thoughts. They delineated four major areas of concern:

1. Improving health status and access to care for the poor - both rural and urban. Several people feared that in its zeal for economic development the Indian government is starving the public sector and overly relying on a private health system. One described a vicious cycle in which as the public lost confidence in the poorly funded public system that loss of confidence was cited as justification for further reliance on private and for profit "solutions."

2. Dealing with environmental health hazards. As an example, yesterday's Times of India descibed staggeringly high levels of multiple drugs in the Andra Pradesh water supply - a result of dumping by pharmaceutical manufacturers. An activist physician stated "It's a global concern - European countries and the US are protecting their environment and importing the drugs at the cost of the people in developing countries." A village woman added -"When the local leaders come, we offer them water and they won't take it."

3. Addressing continuing stigma and ostracism of people living with HIV/AIDS. The National AIDS Control Organization (NACO) and its state branches and multiple NGOs have worked hard in this area, but stigma and ostracism continue to be major problems. (If you're interested in this area, the Yahoo AIDS India e-Forum is a great place to start.)

4. Responding to the torrent of clinical trials from the U.S. and Europe. India has an enormous population of poor people who have thus far been relatively easy to enroll in drug trials that are often poorly regulated (see here for a previous posting on this topic).

These aren't subtle or obscure issues. Like India itself - they're big. Does ethics education have anything of value to offer? I think it does.

If I were consulting to a medical school in India about establishing an ethics curriculum, here are three of the suggestions I would make:

1. I like to think of ethics in terms of three As - Analysis ("what is the right thing to do in this situation?"), Advocacy ("let's do the right thing"), and Administration ("what systems and procedures do we need to help the right thing happen?"). The analytic component , which is dominant in U.S. ethics education, would be less central at the start in India. The key goal of the program should be to encourage health professionals (and other stakeholders) to include responsibility for promoting population health as part of their professional identity, and to suggest ways in which they (whatever else they do) can (a) advocate for improved population health and (b) contribute to administrative measures that support positive actions.

2. Words in a lecture (a more central mode of teaching in India than in the U.S.) or on a page won't foster advocacy skills or administrative understanding. The new ethics education program should be guided by Albert Schweitzer's famous precept: "Example is not the main thing in influencing others - it is the only thing." Students should be exposed to health professionals who have found ways to put population health ideals into action. If the medical school were in proximity to the Vivekananda Memorial Hospital in Saragur, in the state of Karnataka, I would want them to meet with the staff I encountered there (see my posting on the Vivekananda hospital) and for interested students to work there, even for a short time.

3. Finally, I would want the program to be linked to an important area of population health in the local community. If the school was in Chennai, in the state of Tamil Nadu, where the headquarters of the Indian Network of People Living with HIV/AIDS, an NGO founded and run by HIV+ people, is located, learning about the difficulties HIV+ people - especially the poor - enounter in seeking work, accessing care, and maintaining ties with family and community, would be a rich learning opportunity. I would hope that faculty would not simply profess ethics but would put their professions into action, and take students with them in doing so.

Responding to Medical Mistakes in India

For anyone interested in (a) India and (b) medical ethics, (c) the Indian Journal of Medical Ethics (IJME), which is available online, is the key resource.

During my recent stay in Mumbai (I'm in Bhopal now) I met with Sandhya Srinivasan, the executive editor. I learned that IJME was born out of activism. In 1992 a group of reform-minded physicians contested the Maharashtra state medical council election on a platform of "ethical medical practice." The slate lost badly. But the reformers created a newsletter for discussion of ethical issues and promotion of ethical practice. Over time the newsletter became the IJME.

I am especially interested in how the interplay of modernization and tradition in Indian medicine affects ethical norms. By U.S. standards Indian physicians are on a pedestal. I was told that many of the poor see the doctor as "a God on earth." But at the same time western values embodied in concepts like informed consent, physician-patient collaboration, and open acknowledgment of medical mistakes are increasingly part of public discourse.

What happens when "physician as God on earth" meets "physician as collaborator"? The most recent issue of IJME provides a window onto this question.

Dr. Ashok Sinha, a private practitioner in Agartala, the capital of Tripura (a small northeastern state bordering on Bangladesh) discusses - in thoughtful and personal terms - how to respond to poor practice on the part of colleagues. Here are the first two paragraphs of his engaging commentary:

"One of the major ethical issues that I face very often in my practice is whether to criticise my colleagues or not. Complaints, criticism and condemnation lead to terrible consequences and never help anyone, they say. I am told that my colleagues are to be treated like my siblings and I should never criticise them in front of patients.

That seems logical enough. We may or may not agree with a particular diagnosis offered by fellow physicians, and it is not necessary that either of us would be right every time. But to criticise him or her in front of the patient would degrade the whole medical community. Even the patient would be in doubt about whom to trust. Moreover, very often this criticism is fuelled by competitive one-upmanship. Rather than bettering our performance to get ahead, we used the tactic of putting the other fellow down..."

Dr. Sinha reports that "sometimes I spoke out and made myself unpopular, and sometimes I did not, and hated myself for it." But his dominant ethical perspective is that "while we must have loyalty to the profession and the medical community, what about loyalty to patients?"

Dr. Sinha's discussion is followed by two commentaries. Ann Sommerville, head of ethics at the British Medical Association, argues that "in case individual integrity is not enough, doctors also have a duty to take action if they witness evidence of colleagues failing...lessons should be learned, future errors avoided and natural justice dispensed to patients who have been inadvertently harmed." Prabha Chandra, Professor of Psychiatry at the National Institute of Mental Health and Neuro Sciences in Bangalore, concurs. His emphasis, however, is on the need for a practical learning curve regarding how to talk with physicians and patients about mistakes.

The trio of articles strike me as precisely on target. The broad values of honesty with patients and professional responsibility for assessment of practice and self-regulation, do not appear to be culture-bound or limited in their relevance to the west. But values require practical implementation. There is currently very little teaching of medical ethics at medical schools in India, and professional societies do not have strong traditions of self-regulation. I expect the medical community to endorse Dr. Sinha's framework of values, but as Dr. Chandra points out, there is substantial research and skill-development to be done to put that framework into action.

The Ethics of Hypnosis

I've been meaning to write about the ethics of hypnosis since reading Jane Brody's article in the New York Times several weeks ago.

In the early 1970s Dr. Erika Fromm offered a CME course on hypnosis in Boston. I'd heard good things about her as a teacher and I decided to take the course. But like most of my psychiatrist contemporaries I was deeply sceptical about hypnosis. The "you are in my power" stage hypnosis that most of us got our image of hypnosis from seemed like the opposite of thoughtful psychoanalytic psychotherapy, which was at its heyday then.

Dr. Fromm taught "permissive hypnosis," in which the therapist (a) develops the plan for using hypnosis with the patient, (b) defines hypnosis as an opportunity for the patient to access dormant capacities, (c) emphasizes that achieving a hypnotic state is something the patient can choose to do (or not to do), and (d) typically coaches the patient on how to apply self-guided techniques on her or his own.

I was enthralled by the ethics of Dr. Fromm's approach - respectful, pragmatic and collaborative - and impressed by the experience of being hypnotized.

A few years after the course a patient was referred to me for treatment of trichotillomania (compulsive hair pulling). I'd had no experience with the condition and went to the literature. There weren't many good ideas. Medications were the most recommended treatment at the time, but they weren't seen as very effective. The articles I saw said hypnosis didn't work.

My patient was an intelligent, "non-neurotic" person. Compulsive hair-pulling was an isolated symptom. We didn't identify any significant psychological conflicts or sources of tension. I reported what I'd read in the literature. My patient definitely did not want medication, and asked about hypnosis. (Forgive my repeated use of the phrase "my patient." As part of maintaining confidentiality I'm avoiding gendered terms.) I said that the literature didn't suggest hypnosis was effective for trichotillomania.

Despite my report on what the literature said, my patient liked the idea of hypnosis. We agreed that although the literature was dubious about its efficacy we didn't see any significant risks in trying hypnosis other than it might waste my patient's time and the HMO's money. We created an image drawn from my patient's experience (a field of lushly growing vegetation - focusing directly on hair and hair pulling was less promising than a suggestive metaphor) and combined it with relaxation exercises. I made a tape for the patient to use.

It worked.

Twenty years later my patient returned. In a context of increased stress the symptoms had returned. We reviewed the situation and essentially gave a booster shot to the self hypnosis program. Technology having advanced, this time I made a CD for the patient to use.

It worked again. At a follow up meeting before I ended my practice a year ago the symptoms remained in remission.

For me the "permissive" approach to hypnosis, combined with coaching in how to apply the technique on one's own, represents psychiatry and psychological medicine at their ethical best. Clinicians like Erika Fromm took a technique that in its origins was authoritarian and potentially degrading to the patient, and transformed it into a collaborative, educative, empowering approach to self management. Except for treatments conducted when the patient is under anesthesia or otherwise unconscious this is how health care ideally proceeds - with patients understanding the condition, the treatment, and their power to exert an influence.

Fixing American Healthcare - by Dr. Rich Fogoros

In October, when I belatedly came upon Dr. Rich Fogoros's "Covert Rationing" blog, I knew I'd found a kindred spirit. Even though DrRich (his blogging name) identifies himself as a Milton Friedmanite, and I'm New England liberal, we agree that (a) our society has an ethical responsibility to ration health care, (b) that we ration all the time but do it covertly, and (c) our current political culture pretends that rationing is an avoidable evil, not an ethical requirement.

DrRich recently wrote about "Setting Limits Fairly" - the book Norman Daniels and I wrote. Not surprisingly, because we agree on so much, he praised it. Now I'm writing about his book - "Fixing American Healthcare." Not surprisingly, I think it's terrific, and encourage readers to go to DrRich's blog and to read the book.

DrRich presents a "grand unification theory of healthcare" in the form of a 2 by 2 table. The vertical axis goes from low quality decisions at the bottom to high quality decisions at the top. The horizontal axis goes from individual decisions on the right to centralized decisions on the left. This simple framework is very powerful for explaining the mess our system is in. DrRich shows how we've moved from quadrant III (low quality decisions made by individual doctors and patients), which led to chaos, highly variable quality, and escalating costs, to quadrant IV, in which centralized decisions lead inevitably to covert rationing.

What makes covert rationing inevitable is the collision between two incompatible pieces of belief - that access to health care is an entitlement and that limits are unacceptable. DrRich argues that because all members of society contribute to financing the health system the social contract requires that health care must be available to all. It's the delusion that limits can be avoided that has to go. He envisions a system in which a generous but limited package of benefits are available to all, with opportunity for purchasing a wider range of coverage with individual funds.

I especially like DrRich's emphasis on the role "empowered patients" play in the system he envisions. DrRich has practiced medicine (cardiology), written text books and done research. He conceptualizes medical care as a partnership between clinicians out from under the bureaucratic fetters the current system places on them and activist patients. It's a vision of the kind of health care the residents I teach want to practice. Unlike so many of the free marketeers who write about medicine he doesn't reduce caretaking to an arms length commercial transaction between wary "consumers" and chastened "providers."

While each of the ten chapters is replete with pearls of insight, I was especially impressed with chapter 9 - "How to Ration Healthcare." DrRich presents the best thought out practical framework for rationing that I've seen. He uses comprehensible mathematical formulae to show how clinical evidence and core values can be factored into decision-making in a systematic manner.

The most useful part of "Setting Limits Fairly" is its conceptualization of "accountability for reasonableness" - a societal process for fair, open and potentially socially acceptable rationing. If we combine that framework for process with Rich Fogoros's lucid analysis of how specific rationing decisions can best be made, we have the underpinnings of how a society and an actual health system could set clinically informed, ethically justifiable limits.

Now we need political leadership with the courage to tell us what we need to hear!

Ethics at the Swami Vivekananda Hospital

I'm in Mysore, in the South Indian state of Karnataka, for eight days, at the Vivekananda Institute of Indian Studies. The Institute is part of a remarkable twenty five year old non-governmental organization - Swami Vivekananda Youth Movement (SVYM).

I visited for two days at the hospital the NGO runs in Saragur, a rural community forty miles southwest of Mysore. The visit provided a rich perspective on the ethics of health care and health organizations. I've organized my initial thoughts around two questions, both involving the concept of health care as a calling:

1. If health care is a calling, where does the call come from? Dr. R. Balasubramianiam ("Balu"), currently president of the NGO, led a group of medical students at Mysore Medical College who founded SVYM in 1984. Balu described how at 17 he was "ragged" so harshly by the senior students at the engineering college he had enrolled in that he decided not to go back. Since simply staying at home wasn't an option, to cover up the fact that he wasn't at school he started to spend the hours he would have been at the engineering college at an ashram, where he encountered the teachings of Swami Vivekananda (1863 - 1902) and was inspired by Vivekananda's vision of service to the rural poor and of making India an educated, healthy, harmonious society. Medicine, in the form of service to the rural poor, became his calling.

Balu's narration of his traumatic experience at the engineering college teaches one lesson about the origins of medical calling. It typically has strong personal roots. Virtually all of the physicians, nurses and other health care professionals who (a) I admire and (b) I know well enough to ask about their path to health care (c) cite meaningful personal origins of their calling. These vary tremendously, but have in common being intensely important to the individual.

Pictures of Swami Vivekananda and placards with his most quotable sayings are all around the hospital. When an associate of the NGO told me that he himself was an atheist I asked him "if Swami Vivekananda were here and heard you say that - what would he say?" The response was - "the Swami was an atheist himself - he thought that any god who allowed so much suffering didn't deserve to be worshipped. He taught that the religious spirit was shown in service, not in ritual practices."

Dr. Sridevi Seetharam, a physician deeply involved with medical ethics, explained that in Sanskrit terms, the gentleman I quoted in the previous paragraph was talking about the devotional path known as Karma Yoga - "selfless service to others in one's chosen profession or area of work." Vivekananda was Hindu by birth, but taught that all religions are in some sense "true." In addition to the personal origins of each person's calling to health care, the hospital's inspiration, Swami Vivekananda, and the ancient tradition of devotion through a Karma Yoga, which can be entirely non-sectarian and non-theistic, provides an external pillar for the calling.

In the U.S. people of faith can, if they choose, base their calling on their religious beliefs. But the kind of framework the doctrine of Karma Yoga provides, is not part of our secular ethos. The professionals I most admire act as if they were carrying out a devotional process, but if asked to explain the foundation that underlies their care giving, they're often at a loss to articulate it, or say something like "this may sound like a cliche but..."

2. How does calling manifest itself at the organizational level? My time at the Vivekananda Hospital was limited, but:

* The hospital and its outpatient clinic serve a rural population that includes tribal people who are only recently out of the forest. There is a huge social gap between many of the patients and the well educated professional staff. But the professionals evinced an interest in and warmth towards the people they serve that seemed more like love than technical "cultural competence." The physicians we spoke with evinced deep empathy with the patients. One manifestation of this empathy was creation of a strong role for "patient care managers" who come from the rural population and guide patients through their interaction with the care program in a side by side manner. Empathy is also manifested by providing free lodging for family members who cannot go back to their villages at night because there are no buses after 5:00 PM.

* Physicians were remarkably knowledgeable about traditional Ayurvedic treatment methods and Ayurvedic clinicians were part of the staff. Patients whose traditions and beliefs included Ayurveda had access to this approach in a way that was integrated with the allopathic services they received.

* A holistic view of health as involving more than medical relief of pathological states led the hospital staff to initiate a range of other activities including health and hygiene education in the villages, support for school improvement, and promotion of a clean water supply.

* Finally, and most remarkable from an American perspective, the hospital holds a twice a week non-sectarian prayer meeting attended by all of the staff and all of the patients. I was not present for a prayer meeting, and I do not see it as a format that would fit into a secular U.S. institution, but finding acceptable ways of recognizing the calling that all are participating in is a desirable path to follow.

Getting Patients More Involved with Health and Health Care

U.S. health policy leaders are desperate. Despite innumerable studies, policy proposals and conferences, population health statistics continue to decline while health care costs continue to rise. Not an impressive result for all of that analysis!

One of the leading magic bullets proposed for the health system has been "consumer directed health care." The core idea is that if high deductibles put patients at risk for more of the cost of their care they will become (a) more active in promoting their own health and (b) more discerning "consumers" of health care. These are clearly desirable outcomes.

We know that "consumer directed health care" achieves two desirable outcomes. The cost to employers is reduced and the premium cost to individual enrollees is less than their cost would be for insurance without the deductibles. But what about the impact of deductibles on patients. Do they become more active in promoting their own health and sizing up the value of proposed health interventions?

A study from the University of Oregon published in American Journal of Managed Care suggests that the answer is - no.

The researchers surveyed 1616 employees at the start of their enrollment in plans with and without high deductibles and a year later. The key finding was that patients who were higher on a measure of "activation" (knowledge, skill, and confidence in managing one's own health and health care) became more active over the course of a year regardless of whether they were or were not in a "consumer directed health plan." Enrollment in a high deductible plan, however, did not prod patients to become more active.

In other words, in this group of insurees, the magic bullet of "skin in the game" did not transform otherwise passive patients into active "consumers" and self-managers.

Another article in the same issue studied a different approach to change. Instead of prodding patients with financial risk, on the assumption that they lacked "skin in the game," patients were treated as partners, and given the same information about clinical guidelines that their physicians received. Simply providing patients with clinically relevant information increased adherence to evidence based guidelines by 12/5%.

Wise clinicians will not be surprised by these findings. Health has intrinsic worth. It isn't a consumer item that requires financial penalties to make us care about it. Providing patients and clinicians with the same information at the same time is like well-timed therapy for a couple. It points in directions both want to go in.

Two studies aren't definitive, but they suggest a direction that builds on the core values of physicians and their patients. That seems promising!

A Mild Wrist Slap for Pharma in India

Last month, before coming to India (where I am now) I wrote about the drug marketing scene. The posting gave a link to an article in the Times of India that suggested to me that the Indian media were on the trail of the Pharma-Medicine story that is currently exploding in the U.S.

In Delhi I met with Rema Nagarajan, the reporter who wrote the Times of India story. Rema is well-informed about developments in the U.S., such as medical schools banning all gifts to medical students, house officers and faculty. Yesterday she had a followup article in the Times of India that suggests that the exposure of excessive pharmaceutical company influence over medical practice is heating up in India. India does not have the same level of consumer advocacy and consumer protection that has been developed in the U.S., but India is on its way in that direction.

Here are excerpts from Rema Nagarajan's article:

If you thought the government would crack the whip on pharmaceutical companies offering freebies to doctors for prescribing their products, think again. The department of pharmaceuticals has indeed taken note of the dubious practices reported by TOI on December 15, but in a surprisingly mild, almost apologetic tone.

Joint secretary Devendra Chaudhury wrote to the various associations of drug manufacturers on December 18 citing the TOI report, but the letter suggests he would be "grateful" if the associations acted on suggestions made by the department.

...The mild tone is despite the fact that the December 18 letter admits: "The allegations cannot be in any way treated as ethical and something that could be endorsed by society in general. This also puts the pharma industry in a bad light since the enhanced promotional expenditure of the pharmaceutical companies result in enhanced market price of the drugs, which has to be borne by the consumer."

Yet, it says the department would be "grateful if you (pharma associations) could kindly take action" on its suggestions and also take steps to "prevent such perception in the mind of the public and other bodies to obviate misuse of promotional expenditure" and to kindly "prevent allegations as well as media reports on this subject as have appeared".

The joint secretary says in the letter that "the matter being extremely sensitive and of great public importance I am constrained to write to you". With such a mild and apologetic tone from the government it is anyone's guess whether the pharma industry would feel the need to take any action.

Both the Organisation of Pharmaceutical Associations of India (OPPI) and the Indian Drug Manufacturers Association (IDMA) had released their own codes of conduct at the beginning of 2007. However, there is no single code applicable to all drug manufacturers, a fact that the letter points out. But again, this is followed up by a gentle nudge: "You may like to consider having such a code for your members"...

Establishing an ethical balance between medicine and commercialism in India will not be easy. Two very strong forces push against efforts to spotlight the problems and suggest solutions. Fist, there is tremendous trust in physicians, beyond what the profession deserves. (Rema quoted a Hindi saying in our discussion - "A doctor is like a God come down to earth.") Second, Pharma is a substantial component of the national thrust for rapid economic development. Successful enterprises aren't totally untouchable, but they are harder to tame than comparable enterprises in the U.S.

Preaching doesn't create an ethical health system. Public understanding of what constitutes good health system ethics and public demand for accountable performance are required. The media and political leaders are key "educators" for the public. I'll try to glean more about the societal learning process in India while I'm here.

Justice Cardozo on Trust and Professionalism

2008 overflowed with distressing stories about ethical lapses in medicine. In hope that the worst is over I wanted to open 2009 by discussing the best succinct statement I know about what being a trustworthy health professional entails.

In 1928 Justice Benjamin Cardozo was Chief Judge of the New York State Court of Appeals. (Four years later he was appointed to the Supreme Court.) On December 31, 1928 he published the opinion for Meinhard v Salmon. Here's the story.

In 1902 Walter J. Salmon obtained a twenty year lease on the Hotel Bristol on Fifth Avenue and 42nd street in New York, on the condition that he change it from a hotel to shops and offices. To finance the venture Salmon entered a joint venture with Morton H. Meinhard. Meinhard provided the money. Salmon managed the project.

Twenty years later, when the lease was about to run out, the property owner offered Salmon an opportunity to lease the current building plus a larger piece of property for a much bigger redevelopment project. Salmon took the lease without informing or involving Meinhard.

Meinhard sued to be let into the deal on the grounds that the opportunity to renew the lease belonged to the joint venture. Here's what Justice Cardozo wrote on behalf of the court:

Joint adventurers, like copartners, owe to one another...the duty of the finest loyalty. Many forms of conduct permissible in a workaday world for those acting at arm's length, are forbidden to those bound by fiduciary ties. A trustee is held to something stricter than the morals of the market place. Not honesty alone, but the punctilio of an honor the most sensitive, is then the standard of behavior.

As to this there has developed a tradition that is unbending and inveterate. Uncompromising rigidity has been the attitude of courts of equity when petitioned to undermine the rule of undivided loyalty...Only thus has the level of conduct for fiduciaries been kept at a level higher than that trodden by the crowd. It will not consciously be lowered by any judgment of this court. For [Salmon] and for those like him, the rule of undivided loyalty is relentless and supreme

When stories emerged about unseemly financial ties between leading physicians and the pharmaceutical industry the standard defense was "I was honest in all that I did..." If we hear this lame self-justification again in 2009 our response should be - "that's not enough - as a health professional you are held to something stricter than the morals of the market place. Not honesty alone, but the punctilio of an honor the most sensitive, is the standard of behavior you must meet!"

Happy New Year!