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.