The Physician’s Noblesse Oblige—Reviewing our Social Contract!

The Physician’s Noblesse Oblige—Reviewing our Social Contract!
Dr David KL Quek

AGM Aftermath

After the tumultuous if successful close of the last Melaka AGM, I must confess to being a little jaded, disappointed, despondent—perhaps even burnt-out. Events have overtaken our Association, which would in no small measure change completely how the MMA is run or will be run. There are real dangers of usurpation of a few over the many. But I sincerely hope that good will and common sense will create a new era for the future of our medical profession.

Sadly, many of our members out there still remain as busily practice-orientated. Despite appeals to participate more, many have not bothered to personalize their involvement with the MMA, while still expecting the few interested to work tirelessly for them. Most are oblivious to taking part, unwilling to sacrifice a little time and effort, believing that there are others who would surely do their bidding for them. Well, now their apathy and passivity may be their undoing, when they would have even lesser control over the affairs of the MMA, of the medical profession, of healthcare even.

Nevertheless, I have had some weeks of reflection, which have blunted the acid-sharpness of the despair and pain that I had allowed myself to wallow into. Time heals, and this almost always returns me toward what truly matters—to the ideal of medical practice, which is what this profession is all about.

I realize that sometimes we all get too embroiled with so many trivial if narrow issues that we lose out on the sense of our vocation. But truly in a philosophic sense, these are passing events, which might simply create a few small etches or ripples in the fabric of history of our times… C’est la vie…

I wish to revisit in this issue, a review of our professional "noblesse oblige”, our social responsibility as physicians.

Noblesse Oblige

The Miriam-Webster’s Dictionary defines “Noblesse Oblige” as “the obligation of honorable, generous, and responsible behavior associated with high rank or birth”. For the physician such unspoken if tacitly-understood principles of benevolence of helping those less fortunate, are not highborn, inborn or hereditary, but are nonetheless expected by many as obligatory ideals.

In many ways our entry into the medical profession is certainly one measure which elevates us into a new strata of society, one that we’ve been constantly reminded, carries so much trust and responsibilities.

Since time immemorial, the physician has been expected to behave within a circumscribed system of practices, which helped define the healing profession as compassionately embedded with ethics and socially acceptable correctness.

However, for most of us, the practice of medicine is far easier, more mundane and is usually of second nature to us. Our healing art so steeped with such ponderous ideals is more subliminal than of conscious awareness. Although inconsistently taught, almost all medical graduates have been instilled in a culture of caring altruism and empathy toward our patients.

The Hippocratic principles have been seen as the underpinning ethos of how the physician should live out his profession, with dos and don’ts, of what is correct or otherwise frowned upon behaviour, which carries the commission-omission penalty of public reprimand, or censure, or worse...

What is perhaps often understated and less known is that the physician even in the era of the ancient Greeks, were paid for their services. This fee-for-service mechanism had almost always been the mode of exchange of goods and services—sometimes through barter, but more often with agreed upon money, cash or valuables. However, failure to cure or resultant untoward outcomes were also responded to harshly. Physicians were punished, run-out of towns and villages, banished or even killed for their mistakes and less than capable actions!

Thus, the physician has not always been seen to be that quintessential healer par excellence, one that we have grown accustomed to nowadays. (Yes, there are many who remain skeptical as to whether the doctor heals more than harms!) Clearly though, history has never unequivocally accepted the physician as a natural or consistent boon to mankind—we have always had our fair share of detractors.

Medicine’s Detractors & Distractions

Macedonian world conqueror, Alexander the Great, was reputed to have said that “I am dying with the help of too many physicians.”

Thomas Young, in 1815, had whimsically said that “Medical men, my mood mistaking, Most mawkish, monstrous messes making, Molest me much; more manfully, My mind might meet my malady: Medicine’s mere mockery murders me.”

Irish playwright, George Bernard Shaw sneered that, “Medical science is as yet very imperfectly differentiated from common cure-mongering witchcraft.”

Well-known 20th century philosopher, Ivan Illich in Limits to medicine. Medical nemesis: the expropriation of health, 1975, had argued cynically that "In a morbid society the belief prevails that defined and diagnosed ill-health is infinitely preferable to any other form of negative label or to no label at all… More and more people subconsciously know that they are sick and tired of their jobs and of their leisure passivities, but they want to hear the lie that physical illness relieves them of social and political responsibilities. They want their doctor to act as lawyer and priest… Social life becomes a giving and receiving of therapy: medical, psychiatric, pedagogic, or geriatric. Claiming access to treatment becomes a political duty, and medical certification a powerful device for social control.”

Medical historian, Roy Porter also cautions against the growing medicalisation of life: "...an expanding medical establishment, faced with a healthier population of its own creation, is driven to medicating normal life events (such as the menopause), to converting risks into diseases, and to treating trivial complaints with fancy procedures. Doctors and 'consumers' alike are becoming locked within a fantasy that unites the creation of anxiety with gung-ho 'can-do, must- do' technological perfectibilism: everyone has something wrong with them, everyone can be cured."

In fact many people and historical leaders had in the past almost always lamented the fact that the doctor was associated with more suffering and questionable consequences than success or cure. French Emperor, Napoleon had said that “Medicine is a collection of uncertain prescriptions, the results of which, taken collectively, are more fatal than useful to mankind. I do not want two diseases—one nature-made, one doctor-made.”

That chancy “luck” or for want of a better prediction for many a serious ailment had often been entrusted to the final arbiter of “fate”—that last gasp opinion or prognostication of the physician. Until the recent past (late 19th century), most doctors could possibly diagnose but not really treat, but only predict when death was imminent, and hence, they were often not terribly successful at healing or saving lives!

Thus, the serendipity of healing was more or less as predictable as a throw of the dice, not the so-called healing touch of the physician who prescribed unverified bleeding (venesection), simplistic use of induced vomiting emetics, “poisonous” herbs and chemicals, and prayers—that magical salve that conquered or consumed all!

Debacles vs. Public health success

Most if not all ill patients prior to the nineteenth-twentieth century, got better due to one’s natural recovery process, in spite of the occasional interference by the physician. The unwashed hands of the obstetrician killed more women through puerperal sepsis than was recognised for decades, until antisepsis (pioneered by Hungarian Ignaz Semmelweis) and asepsis (Lister) techniques gained ground, ever so reluctantly due to huge egos of famous physicians!

Nevertheless, the past 100 years or so has showcased the relentless march of success of the illness-wellness health model. There can be no denying that the 20th century had produced a paradigm of health care practices which had not only enhanced scientific knowledge and understanding, but more importantly, produced a consistent if changing array of curative therapies, previously quite unheard of.

Through public health measures, better public and personal cleanliness and sanitation, common communicable diseases have been drastically reduced, except in the poorest pockets of the developing world. Cures either via medicines or surgeries have transformed the landscape of disease and ill health until there is so much hope and hype that modern medicine could perhaps soon heal all and sundry! Longer life expectancies and good quality of life are now the norm rather than just for the privileged few.

Yet, as we enter and dabble into newer realms of scientific knowledge, into the very heart of individual-based personalised gene-based therapies, and finer and finer skilled surgical expertise, aided by technology and even robotics, the margins of possibilities rather than promises continue to blur.

Touted evidence-based practices compete with newfangled if unproven hi-tech hype, which pushes the envelope of stupendous progress and advancement, but at huge uncontainable costs! The success principle also translates into wishful expectations that everyone should be entitled to the very “best” of healthcare and medical expertise that modern medicine can offer.

Dr Herbert H Nehrlich, an English private practitioner wrote to say that (BMJ 2004;328:770 (27 March), doi:10.1136/bmj.328.7442.770-a): “Our real enemies are the powers that aim to make us dependent: the merchants who try to sell health care as a proactive entity rather than a reactive one. They offer free examinations, and they manipulate long established laboratory measurements, all in the name of more profit. They go hunting for potential new patients and persuade them that they need treatment or ‘preventive’ measures. They deliver ‘health care’ to the eager, brainwashed consumer like the milkman delivers milk. But they often come empty handed. They do not owe you anything, but they promise much.”

Under this scenario, the greater the perceived success of the healthcare model, the greater have been the expectations; and the greater the demand for access and equity by one and all. Malaysians now expect that everyone should have equal and immediate access to an undisclosed if unlimited tranche of healthcare services.

Malaysia’s rising expectations

In Malaysia, we do have an enviable position of having done remarkably well in terms of primary healthcare infrastructure. For decades now following independence, we have had a fantastic run of well-planned and executed healthcare policies which saw the widespread development of rural and semi-urban community clinics (Klinik Kesihatan), almost all of which are within 5 kilometers of public reach.

A reasonable basket of services are provided including the essential maternal and child care services which incorporate mandatory maternal checkups and childhood vaccinations, as well as certain simple primary healthcare treatments, accessible to everyone at most affordable costs, i.e. almost free, and provided for via tax allocations.

For the urban sector however, tertiary public hospitals at state capitals have also been modernized at huge costs to keep up to date with modern advances in secondary and tertiary care. They are complementary to looking after more complex admissions and surgeries.

However, the development of the healthcare sector in the urban setting has been rather laissez faire.

Beginning in the 1980s, there was a tacit nudge to allow the somewhat haphazard sprouting of private clinics and private hospitals to offload the seriously overcrowded government clinics and hospitals. Without doubt, these private clinics have to some extent enabled most city-dwellers to have ready and reasonably affordable access to healthcare.

The National Health & Morbidity Survey 2006, showed that some 62% of patients actually look to the GP for first access to healthcare. These GP clinics of course offer real choices for those urbanites who are unwilling to queue with the overcrowded public sector outpatient services. Such has been the unheralded contribution of the GPs for so many years.

Unfortunately, many of these doctors who have been placidly if single-mindedly plying their trade and unspectacular services for years on end, also lack a collective voice, so much so that their rights and livelihood have been shortchanged, when seemingly more and more regulatory exercises appear to have been foisted upon them. Of late the role of the private GPs and hospitals have been questioned and debated, especially when costs of care appear to have escalated beyond many people’s expectations.

Escalating Healthcare costs

Alas, as we enter into the new century amidst financial uncertainty, healthcare costs the world over have reached critical proportions, which threaten to undermine the very fabric of social services expected by every population at large. No matter the mechanisms of healthcare payment or system of cost-sharing, expenses continue to escalate to the point of painful limits of public affordability, and even personal-familial bankruptcies and indebtedness.

In the USA, this has reached 16-17% of the GDP, a staggering 2.3 trillion dollars! Most other first world countries spend some 10% of their GDPs on healthcare, while rationing and forced containing the rising costs and services. The concept of universal access to healthcare services is fast becoming fully tested as demands continue to outstrip the supply side limitations—instant unlimited service for every demand for healthcare for all, appears untenable and unsustainable.

Wait times, queueing and rationing, with denial of newest if promising but untested experimental therapies will progressively become the modus operandi for all nations. There is no free lunch even if one opts for the best most comprehensive insurance or co-payment mechanism, some form of social insurance or special taxes, etc.

In Malaysia, our healthcare budget just tops 4.7% of our GDP, with 2.2% coming from the public purse—a total estimated healthcare expenditure of around 35 billion Ringgit. There has been a cutback of some 4.8% in the last budget, which implies that the private sector was supposed to take up the slack, through greater investments as well as private initiatives. Yet from our national healthcare accounts, we have been warned that our private out-of-pocket (OOP) spending (~57%) on healthcare is too high, and might not be sustainable in the long term.

Thus, we are thus at a crossroads. We have a modern well-equipped and potentially quite proficient secondary to tertiary healthcare system, which can provide up-to-date care for most if not all ailments including catastrophic illness, such as state-of-the-art surgeries and anti-cancer therapies.

Yet, we have a less than systematic system of payment mechanism, which creates technical gridlock and delay in access for some of these demanded treatments. We have no declared universal access to healthcare for all our citizens, although for most basic medical care, this is offered at token subsidised rates—RM1 to RM5 for outpatient primary or specialist care respectively and hugely subsidised in-hospital care upwards of 98%! Still, demands for rapid access to tertiary treatment have snowballed, until we can no longer sustain the cost without essentially cost-constrained rationing.

Healthcare Review/Reform, soon?

We recognise that the government is very sensitive to the public perception of what should be offered as a benefit of citizenship, i.e. greatly subsidised healthcare. We also know that the public has been very vocal and averse to any talk of revision of this “social contract”. But this subsidy quantum has to be redefined sooner than later. We simply cannot afford this, notwithstanding the fact that everyone clamours for greater accountability or stringently containing wastages and leakages, whether political or bureaucratic.

Thus, we understand the need to reform our healthcare system. We would have to find a more sustainable model where more of our citizens can be served well, without the cost escalation bankrupting our public purse.

We need to devise a better more comprehensive system of copayment through a form of either specially allocated healthcare tax, or a community-rated national health insurance, which embodies every citizen and his/her dependents.

We need to integrate or closely align our now dichotomized public-private sectors, so that there will be better utilization of limited resources and less duplication or wastage. We need to persuade our people that this is truly the only way forward. Everyone has to wake up to the fact that he or she has to take responsibility for his/her own health. The government can no longer be left to shoulder this alone.

As physicians, we have to do our part, and engage our patients to recognize this enlightened truth. Of course we will expect better and more prudent use of public funds. We will expect greater productivity and fewer leakages from unnecessary cosmetic or wasteful enterprises. Administrative and bureaucratic expenses must be sharply curtailed and brought down to a minimum.

Whatever the reform, we must set a new paradigm of accountability and economical utilisation of our very finite resources, which are contributed to by everyone—this will engender greater ownership and prudence, ensuring more equitable and fairer treatment for all. We must review our social contract, even as we strive to provide and preserve our social safety net for the most indigent and underserved.

As physicians we can help by ensuring that the authorities and our patients fully understand our benevolence and our sacrifices—we will temper our free-market instinct with altruism provided we are sure that this applies best for the most people in Malaysia. But we must be assured of our just remuneration and our livelihood, we must be given sufficient rewards to justify our calling for excellence and temperance, above the rising tide of mediocrity and despondency…