malaysiakini: Unbiased treatment for all

Unbiased treatment for all

David KL Quek
malaysiakini, Mar 23, 10
1:28pm

 
New York Times columnist Professor Stanley Fish, (April 12, 2009) wrote about 'Conscience vs Conscience', where he discussed the conundrum about how people in general and physicians in particular, under different circumstances should or shouldn't abide by their own conscience per se.

The contending issue was that physicians should not refuse treatment or procedures based on their own personal moral or religious grounds. Conversely, any doctor should not be differential or partisan when treating patients who may have a different predisposition, political or religious leaning from oneself.

Fish argued that there is such a thing as a collective “public conscience” which should supersede that of one's personal conscience and value systems, no matter how entrenched these may seem to be.

During the George W Bush administration, the culpable clause, called the Provider Refusal Rule, allows healthcare providers to refuse to participate in procedures they find objectionable for moral or religious reasons.

The main bone of contention was of course regarding freedom to choose abortion, pro-choice, or conversely to advocate pro-life.

In Fish's article, he underscored an earlier statement by Mike Leavitt, Bush's secretary of health and human services, who had said that, “Doctors and other health providers should not be forced to choose between good professional standing and violating their conscience.”

The direction of the Bush doctrine was of course to urge the conservative right against unfettered abortion on demand, which continues to divide the American people.

Fish reviewed the etymology of “conscience” as ascribed to English philosopher Thomas Hobbes. Here one of the earliest definitions of conscience, referred to those occasions “when two or more men know of one and the same fact . . . which is as much to know it together”, and where, violation of conscience meant that knowing together, men prefer their “secret thoughts” to what has been publicly established.

Fish acknowledged that Hobbes understood that many people define conscience as being the private arbiter of right and wrong. But Hobbes regards this as a corrupted usage invented by those who wished to elevate “their own . . . opinions” to the status of reliable knowledge and try to do so by giving “their opinions . . . that reverenced name of Conscience”.

Hobbes's main argument is that if one can prefer one's own judgments to the judgments of authorised external bodies (legislatures, courts, professional associations), the result will be the undermining of public order and the substitution of personal whim for general decorum: “. . . because the Law is the public Conscience . . . in such diversity as there is of private Consciences, which are but private opinions, the Commonwealth must needs be distracted, and no man dare to obey the Sovereign Power farther than it shall seem good in his own eyes”.

It must be borne in mind that during that era, the word of the King and his aristocrats were considered sacrosanct, which must be obeyed on pain of severe punishment or even death. In most modern societies however, the rule of law necessarily dictates that the nation's laws and constitution must reign supreme, although varying interpretations and amendments are now allowed based of intellectual arguments of merit.

Ethical underpinnings

Where does this leave the medical professional when it comes to ethical underpinnings of doing what's right or wrong? Would our personal conscience suffice?

Or, should we subsume to the greater wisdom of our collective professional voice (for example, national medical associations, professional bodies, world medical association, medical councils, etc), which through the long arduous passage of time and historical experiences, would have honed a burnished if strait-jacketed version of what's generally accepted as “ethically and publicly correct”? Or should he or she bow to the will of a superior authority - in other words, simply listen and obey orders?

Be that as it may, does this mean that the medical professional would then have no right to rely on his own personal conscience and moral standing? Obviously, the answer must be 'No', because the physician while suppressing his own conscience would have to bow in no uncertain terms to the interests and will of the patient, whom he has undertaken to look after, to assess or to treat.

The main tenet of medical professionalism is to advocate the best interests and benefit of the patient, with the most dispassionate and independent proficiency as possible. On one hand, if one's convictions appear to run counter to public expectations, then surely - if these are so diametrically opposed to the greater wisdom of peers - one has to justify one's personal convictions all the more.

Again, this cannot be taken out of context. In certain circumstances, the medical professional is called upon to make extreme judgement calls, which can be sorely tested by either undue influence, threats from or fears of authority (for example, police, superior officers, military, even political powers) or worse, direct or indirect 'rewards' for passive compliance, obedience.

Doctors shouldn't be biased

The 1st century AD Hindu code, 'Caraka Samhita', exhorts doctors to “endeavour for the relief of patients with all thy heart and soul; thou shall not desert or injure thy patient for the sake of thy life or living”, which have been restated in many codes of professional conduct, including our own.

Yet, these are often pushed to the backburner when conflicts of duties arise.

Recent public spats over medical testimonials and reports have arguably cast long shadows as to the so-called impartiality, ethics or professionalism of some of our medical colleagues. Forensic pathologists are facing some intense scrutiny of late, due to questionable lapses, incoherent practices and perhaps even perceived selective memories, and slipshod standards of duty of care.

Other physicians making medical reports have also been put under the microscope for their perceived bias or slant of their reports, one way or the other, until the truthfulness of one vs. the other, appears difficult or impossible to discover!

Such ambiguous if disingenuous medical findings or reports cast a dismal if disappointing view on our profession, our health service. While some of these appear coerced, some might conceivably be simply venal, just as if medical veracity can be made to sway according to the purchasing power of the most damning and powerful!

Physicians must be reminded that for that patient (deceased or detainee) under his/her charge, there is frequently no other person whom the victim's interests can be represented, except from the physician's unbiased assessment.

Sadly, some of these dubious practices place us at odds with the perceived wisdom and conventions of some greater external collective conscience. These conventions although seemingly unenforceable, have long been articulated by world authorities such as the World Medical Association and even the United Nations Human Rights Commission.

The Istanbul Protocol of the UN High Commission for Human Rights is categorical in stating that: “Dilemmas arising from these dual obligations are particularly acute for health professionals working with the police, military, other security services or in the prison system. The interests of their employer and their non-medical colleagues may be in conflict with the best interests of the detainee patients.

“Such health professionals with dual obligations, owe a primary duty to the patient to promote that person's best interests and a general duty to society to ensure that justice is done and violations of human rights prevented. Whatever the circumstances of their employment, all health professionals owe a fundamental duty to care for the people they are asked to examine or treat.

“They cannot be obliged by contractual or other considerations to compromise their professional independence. They must make an unbiased assessment of the patient's health interests and act accordingly.”

Unfortunately, this protection by convention appears so remote to the lonely physician standing in the clutches of perceived authoritarian powers, whose oppressive influence can seem imaginably overpowering.

Society to lend a hand

Seen in this context, society must exert its moral imperative of the public good on a universal basis, and demand the application of such universal conventions and norms, to protect the hapless physician at the centre of such political or partisan storms, lest such pressure lead to further erosion of already debilitated institutions, and demean justice.

Similarly, the onus is on members of the medical profession to remain steadfast to the doctrine of public conscience and universal principles rather than personal ones, when carrying out our duties, including when making judgement or pronouncement on some of our possibly errant patients under our charge or even our own colleagues. Sectarian perceptions whether religious or political, clearly must take a back seat, and should not be allowed to colour our thinking or decision making.

Personal bias or experience or even conviction should yield to the more nuanced, perhaps more balanced decisions based on strict interpretations of medical truths, diagnostic facts and findings, proper statutes, codes of professional conduct, and perhaps legal precedents.

The US Supreme Court has ruled that when the personal imperatives of one's religion or morality lead to actions in violation of generally applicable laws - laws not promulgated with the intention of affronting anyone's conscience - the violations will not be allowed and will certainly not be celebrated; because: “To permit this would be to make the professed doctrines of religious belief superior to the law of the land, and in effect to permit every citizen to become a law unto himself.”

Therefore, we must be quite clear to dissect our dilemma as to which is the superior right - doctors must be truth-seekers, and ultimate final independent arbiters of medical discovery.

Similarly, in the context of political or authoritarian pressure, where risk to the individual may seem likely, it behooves the professional to be reminded about the World Medical Association's 'Declaration of Geneva', which is a modern restatement of the Hippocratic values, as well as to be cognizant of UN Conventions such as the 'Istanbul Protocol'.

Doctors are reminded that the health of their patients is their primary consideration and that they must devote themselves to the service of humanity with conscience and dignity.

We must learn and adhere to our historical memories, that which are collectively acknowledged as 'correct' and first and foremost for our patients' interests. Certainly, in this context, every professional should not let religious, political or sectarian persuasions from influencing his/her decision making, that choice of what is right, or wrong.

But does this mean that these are 'moral' fixtures, which cannot or should not be modified with the passage of time. Or, could these perhaps shift in tandem with the 'fashion' or faddism of current perceptions or even societal movement or direction?

Clearly this will depend on the circumstances and the human aspects of all patient-physician interactions. Although ethics these days are not as immovable or as permanently cast in stone, societal views do evolve. Like sometimes shifting tides, ethical perceptions may very gradually ebb and flow, gradually nudging sand dunes of outlook one way or the other, but often anchored solidly via moorings and underpinnings of moral public good, and greater and greater foundations of universal values.

So changes may occur, but again these must be based on contextual interpretation which should be carefully justified so that the newer interpretation can withstand scrutiny and/or rigorous re-examination, by an increasingly knowledgeable public and also by even more discerning generations of similar professionals.

Thus, personal conscience and public conscience must be employed together to shape our moral compass when we are dealing with ethics and medical professionalism. It helps when we all undertake to reexamine our own values and learn more and more as to how these ethical dilemmas and questions are evolving in this day and age.

We must not be cowed into a mindset of choosing the most convenient way out, or of personally safe, but callous even corrupt expediency.

DR DAVID KL QUEK was the editor-in-chief of the MMA News (bulletin of the Malaysian Medical Association) for 11 years and is currently president of the MMA.

“Few will have the greatness to bend history itself,..."

MMA President’s Inaugural Speech

49th MMA AGM, Friday, 29 May 2009, Sunway Resort and Spa Hotel

“Few will have the greatness to bend history itself, but each of us can work to change a small portion of events, and in the total of all those acts will be written the history of this generation”
~ Robert F. Kennedy

Y. Berhormat Dato’ Sri Liow Tiong Lai, Minister of Health, Malaysia,
Y. Berbahagia, Tan Sri Dato’ Seri Dr. Hj. Mohd lsmail Merican, Director-General of Health Malaysia
Y. Berusaha Dato’ Dr. Khoo Kah Lin, Immediate Past President;
Y. Berusaha Dr. Mary Cardosa, first ever lady President-elect of the MMA,
Y. Berusaha Dr. Koh Kar Chai, organizing chair of the MMA 49th AGM, chairman of the Wilayah branch of the MMA
Y. Berusaha all Past Presidents of the MMA
Y. Bhg. Tan Sri-Tan Sri & Puan Sri-Puan Sri, Dato’-Dato’ and Datin-Datin,

Honoured guests, friends & fellow colleagues,
I stand here today humbled by the task before us, grateful for the trust you have bestowed upon me, mindful of the sacrifices and efforts borne by so many of our distinguished forerunners. Over the past 49 years, there have been 44 presidents of the MMA.

Gratitude & Acknowledgements:
I must acknowledge that over the years, I have been blessed for having worked with and having been mentored by some of the most respected pantheons of our medical profession.

I for one have learnt and benefited much from the vision, wisdom, philosophy, selfless commitment and impactful legacy of such great leaders.

I would like to acknowledge today, the leaders within the MMA whose ideas and ideals have personally helped inspire, shape and mould my professional character, they are:
• Dato’ Dr. Ronald McCoy,
• Dato’ Dr. Abdul Hamid Abdul Kadir,
• Dato’ Dr. TP Devaraj,
• the late Dr. MK Rajakumar.

Among others in the medical and health care scene who have taught, impressed, educated and supported me, especially in the statecraft, tenacity of purpose and dignified diligence of medical leadership are:
• Tan Sri Dr. RP Lingam,
• Datuk Dr. Athimulum,
• Datuk Dr. Yeoh Poh Hong,
• Dr. Milton Lum,
• Dato’ Dr. Lee Yan San,
• Dato’ Dr. Khoo Kah Lin,
• Datuk Dr. Arumugam,
• Datuk Dr. Teoh Siang Chin
• the late Dr. Tibbs Fernandez, and
• the late Dato’ Dr. Lim Say Wan.

I believe that as we endeavour to continue the legacy of our common mission, we have always to stand on the shoulders of giants before us. Clearly in my mind, these are our giants! Much can be learnt from their incalculable institutional memories.

At the personal level, I must also thank my parents, my mum Cecilia and my late father Paul who taught me Christian values, patience, hard work and perseverance. I’m sorry my late father did not live long enough to see me lead this esteemed association. Thank you Mum and Dad!

My wife and soul mate, Bae Ling, is my confidante extraordinaire, my sounding board, my other conscience and my better half! Thank you for still being there for me!

To my children Timothy and Samantha, thanks for being the sobering anchors which make my life worthwhile. I love you all!

Challenging Past Crises
The past several years for the MMA have been challenging and contentious. There appears to be a growing sense of dissatisfaction, of negativism, of frustration, as a result of real or imagined injustices. Perhaps, this is a sign of the times we’re in.

Partisan politicisation had cast blinding shadows over our greater purpose. I believe that not to recognize these problems would be remiss!

Although we went through an era of uncertainty and at times quite bitter acrimony, I believe that we have all emerged shaken, but stronger. In the final analysis, good sense and compromise through sincere dialogue, give and take, rather than rhetoric and innuendos triumphed.

We recognize that misunderstanding and differing interpretations of executive or councilor decisions or indecisions can sometimes blow up into seemingly uncompromising, implacable positions of conflict. Our fragile association can ill afford this.

In resolving crises such as these, we must remember that mistakes or miscues are often committed without willful intention to cheat or defraud the association or its members.

Perhaps, this collective angst reflects the eroding level of trust in our society. Perceived wrongs and highhanded antics seem to pervade our day-to-day experience, disturbing even shocking our accustomed equipoise and sense of fair play. Despite this, we must learn from our human foibles, and move on.

I respect dissent as a legitimate facet of any democracy. On the other hand dissenters too must also recognize realities for the common good. Whatever personal misgivings, we must respect the views of the majority, which must be the supreme arbiter of what our members want and decide.

Every member should seriously consider the wellbeing of the MMA. We must not become bogged down by things and affairs past, so much so, that these begin to stalemate our progress.

I would like to quote political scientist Geoff Mulgan (one of Britain’s top 100 intellectuals) who said:

“Good government should be illuminated by the future. But many governments live with their eyes on the rear-mirror, refighting ancient battles, and reigniting ancient enmities.”

Of course, we must learn from such crises, but these should create opportunities for improvement, rather than spawn paralyzing pessimism and skepticism. It is by being involved and engaged that we as concerned members, can help shape and guide MMA’s direction and purpose.

In my tenure as president, I hope to rise above such unconstructive activities from derailing our administration and policies. I will adhere to principles of greater transparency and accountability. I fully respect the fact that leadership styles are very personal and unique.

Dato’ Khoo had emphasised his softly-softly consensual approach, but this does not imply that mine would be so much more different! My approach however, will be somewhat more cerebral, a tad idealistic, and perhaps more based on principles rather than on tightly focused mundane issues.

Yet, I firmly believe that the MMA should be more expansive in its reach and its attention.
That said, we deserve the leaders that we have sanctioned to serve us, because we—the members—by ballot or by default, have elected them; as I have been, by those of you who have voted.

However, this sense of purpose and connectedness must belong to our members at large out there, whose voices deserve to be heard. Their choice of electing whom they want, on deciding the direction and purpose of the MMA, must not be taken away.

As the 45th president of the MMA, I will try my utmost not to disappoint you. I will do my level best to uphold the dignity and the prestige of our esteemed Association.

But we will need everyone’s help to make our association stronger, more relevant and more in tune, to tackle our staggering professional issues ahead.

Personal Journey
Although I have had ambitions to be a doctor since I was very young, I did not until recently envision that I would lead the MMA, some day.

It is indeed sobering to note that I’ve now been a physician for almost exactly 30 years…
30 years may be one generation for man, but for our profession, this would have been many generations of subtly and variedly taught doctors. We have had many newer crops of doctors, even more interested stakeholders and infinitely more complex healthcare issues!

The healthcare scene has evolved into a tremendously complex if unwieldy behemoth. We have cutting-edge technologies, avant-garde disciplines, greater skills, fashionable cures, newer hopes, yet unexpected newly deadly emerging diseases. Importantly, the expanding number of players and stakeholders and its escalating costs, have created this incredibly convoluted industry, which is undermining nations, the world over.

Therefore for the medical profession, we will need stronger, more decisive leadership, more focused directions and more meaningful motivation to achieve our goals. We need to harness and guide preferred methods of the way we practice medicine and how we conduct our future professionalism, resonant with the needs and expectations in this modern age.

The way we perceive medical care, interact with each other and our patients have all changed. Thus, I am keenly aware that trying to helm a cluster of highly intelligent and opinionated professionals will be even more challenging, sometimes exasperating, and often nerve wrecking. To address these challenges, will require the cooperation and understanding of all of you, our members.

Those of you who know me better, will know that I can be rather blunt and forward. Yet I am not one to take disagreements or harbour criticisms personally. I believe in the robust and fearless exercise of good ideas and well-reasoned arguments, anchored on solid ethical moorings, to help mould and influence society in whatever small ways possible—to enhance society’s worth and perhaps in a ‘pretentious’ way, even to help better mankind, in our little corner of the world!

I am that perpetual optimist who believes that some little good can and does emerge despite the overpowering cynicism and despondency that abounds in today’s world.

More than 10 years ago when researching for an editorial that I was writing, I was touched by what a singular exhortation, by the late Senator Robert F. Kennedy, a visionary leader imbued with an uncommonly passionate sense of humanitarian ideals and moral standing. He had said, and I quote:

“Few will have the greatness to bend history itself, but each of us can work to change a small portion of events, and in the total of all those acts will be written the history of this generation ... It is from numberless, diverse acts of courage and belief that human history is shaped.

“Each time a person stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, these ripples build a current that can sweep down the mightiest walls of oppression and resistance.”

These are the persuasions that I hope will guide my journey as I take on the onerous mantle of the MMA presidency. I believe that each one of us can participate by doing one act of random kindness at a time, one by one by one…

What is MMA’s Relevance to Today’s Physicians, to our rakyat?
Not for the very first time, the question of MMA’s relevance to today’s Malaysian doctors has been raised. Some years ago, such a timely question was raised by our very own DG of Health, who had noted our less than representative membership numbers and our occasional meandering directions.

With our membership growing so slowly or stagnating even, in spite of the huge increase in number of registered doctors in the country, it appears that our representation is quickly but surely contracting.

Our 8,201 members now pale in comparison to the more than 25,862 registered doctors nationwide—a mere 33%! Thus MMA represents only one-third of all our doctors, and the percentage is likely to decrease with each passing year. Nevertheless, the MMA remains the largest association representing doctors in this country.

Some have said that perhaps our time and influence has passed—that the MMA is no longer relevant. Some others have insinuated that MMA no longer carries the commitment or the clout of representing doctors’ interests.

Has the MMA been protecting our vaunted professionalism?

Have we been defending our more than straitjacketed practice issues?

Sadly, we must admit that there have been moments when we appear to have been floundering. We’ve been so engrossed with our own parochial infighting; internecine strife and politicking that we have failed to see the larger picture out there. We appeared to have lost our bearings.

We appear to have forgotten our purpose of serving our members. We’re seen to have been silent when certain of our medical professional interests had been encroached upon. I dare say, somewhere along the line, we have somewhat lost the plot that truly matters, at least that is the general perception.

For one, I do not believe and cannot accept that the MMA is a fraternal club just for pandering to some insular interests. It is not a boys’ club. It has to be more than that.

Perhaps, this is the time to rein in our baser instincts, tame our selfish inward-looking fixation, and finally get down to the brass tacks of leading and working for the doctors, and ultimately benefiting our patients. There really is much to be done, and we have precious little time to work on so many pressing problems and issues.

It is in this light that I wish to now address the issue of medical leadership. I am convinced that we have to start addressing where we’re heading, what our advocacy and policy issues are, for continuity and modernization of our medical association.

Interestingly, in yesterday’s MMA Annual Lecture, Dato’ Dr. Abdul Hamid had raised so many similar questions, despite the fact that we have not at all communicated on these issues, recently! Somehow, we seemed to have aligned our thinking that we have to take “the road less travelled.”

The MMA must seize our role and stamp our relevance!

We must learn how to harness and use our ‘power’ as the premier national representative body to help shape and influence national health issues, policies and direction. We have to encourage our younger leaders to come forwards and engage themselves with greater passion and enthusiasm.

Above all, we must move beyond our petty obsessions, important while these may appear to our limited frames of mind. We can better channel our energies toward greater, more purposeful activities, which enhance our medical profession and our practice conditions.

We must try and show our non-member doctors that we are still a force to be reckoned with; that we are indeed espousing their interests and welfare. We must enlighten them that they have a duty to join us so that we may have a bigger say and mandate when we pursue dialogues and representation with the authorities that be.

We must show that the MMA is the best hope for meaningful input and voice of the medical profession. We should actively work towards and gain more membership numbers.

We must not shortchange ourselves by trying to dis-empower members because of perceived slights, prejudices, or even ethnic racist considerations, that has been raised at today’s AGM discussions. We must not drive them even more into their comfort zone of apathy and resignation!

We must offer unselfish mentorship, by taking greater interests and willingness to learn new and contemporary knowledge and information about health care issues. We must recognize that we are not working in a vacuum, but in an environment beset by seemingly unpredictable challenges.

If representative members of our profession are blasé or ignorant of the changing landscape of our health care issues, we will be left behind. We will not be credible dialogue partners with other stakeholders of the health care industry, including the Ministry of Health.

Therefore, we must learn to identify important national-level issues, gain more in-depth interests and knowledge so that we can play a more meaningful role in helping to modify or revolutionize policies, which ultimately require change for the better. We must strive to remain relevant and engaged.

What are our Leadership Roles & Responsibilities?
I strongly believe in the natural dynamism of physicians—whether we are aware of it or not. As doctors, we are as in almost every society, natural leaders. Some may argue that unfortunately perhaps, not too many of us are emotionally or politically savvy enough, i.e. our EQ is simply too low!

In fact most of us are quite utterly apolitical and apathetic: we just want to work and get on with our own lives—most of us believe that we are simply doctors with a healing profession, and we’d like to be left alone to do just that…

However, this is too simplistic an attitude. Like it or not, we will continue to be buffeted by powerful winds of change and challenges, because health care has become too incredibly complex, too expensive, and too business-like. 13 billion ringgit or 7% of our national budget, in terms of the economic cake, is simply too big to ignore!

Therefore, it is naïve to imagine that we can simply ignore our role and our responsibility in trying to come to terms with its huge implications.

We must harness smarter Partnerships with all healthcare stakeholders
As physicians with unique talents and astute intelligence, we have that great and diverse capacity to infuse illustrious ideas and illuminating concepts, which can help further our healthcare governance and critically relevant practice issues.

As physicians, we can help direct forward-looking, on-the-ground policies, because we are at the forefront of this dynamic of constantly engaging with our patients, what ails them, and then some more.

We are our patients’ keepers
As medical professionals, our patients are our raison d’être, our sine qua non for existing. Without patients, there’d be no reason for doctors to exist, period. But because there will always be those who are ill, who fall sick, who become injured, there will always be need for a healer to answer to this social, this professional calling. We should thus, not be too willing to abdicate this role!

Importantly, as more and more of our role as physicians come into conflict or competition with society’s other demands, we must remain steadfast as our patients’ strongest advocate.

The rising role of insured care, managed care necessarily demands some degree of rationing and sometimes denial or delay of more costly or disputed medical or surgical therapies. We must ensure that such constraints do not lead to adverse consequences for our patients.

Responsible ‘gate-keeping’ must not infringe upon our ethical practice to place our patients’ interests first, and not the other way round! Similarly, the converse of placing our own vested or venal interest first is also wrong and is an unacceptable moral hazard.

Physician autonomy must be defended, protected, supported
Recent controversies regarding forensic medical examinations and reports have posed a serious dilemma and cast a cloud of dreaded fear among medical practitioners. Our professional autonomy has been threatened.

At this juncture I would like to state categorically that I have no political agenda, but only firm personal convictions of what is ethically correct—I have always subscribed to stringent beliefs in universal sociopolitical and human rights, which transcend personal ambitions or self-interests.

I have always had the greatest respects for our colleagues at the Ministry of Health, particularly the DG of Health, and have admired their great dedication to service as well as their goodwill towards our professional brotherhood. We have had and still have an excellent working relationship with the MOH. What we are more concerned with, are the other instruments of power where misguided authorities have acted with increasingly arbitrary sometimes, extrajudicial excesses.

I firmly believe that any pursuit of better ethical standards is not irregular or out of place. Adherence to rigorous edicts of correct medical behaviour in line with our other medical brethren globally, can only elevate to higher standards our medical professionalism, especially vis-à-vis difficult thorny conditions under state constricted landscapes.

Thus, as party to such universal medical ethics, the MMA must forcefully endorse the right of our physicians to act independently and without fear of reprisals from state agencies, which might have their own directed or political agendas. The recent pressures and possible political and police intimidation on doctors making medical reports or autopsies must be strongly opposed.

As physicians, we must always stand on the side of the presumed innocent, the detainees, including every prisoner. We must insist that all custodial deaths should be fully investigated. Indeed in any modern society, custodial coercive techniques, injuries or deaths should be things of the past.

Simply put, there should be no carte blanche to torture any person in custody no matter the circumstances or suspicion of guilt. The arbitrary presumed greater good for the majority should never override that irrevocable civic right of the individual.

The Tokyo Declaration on Torture by the World Medical Association has clearly delineated where physicians must stand on this issue, without compromise. As medical doctors, we cannot be complicit in these possible excesses of authoritarian abuses—otherwise we all stand accused of tolerating our own little ‘Guantanamo’ or ‘Abu Ghraib’!

Thus, in line with our consistent premise and accord with the World Medical Association, the MMA must lead and will engage vigorously to defend our scrupulous position on such ethical and practice issues, under my leadership. We will not shy away from issues, which might be deemed too politically incorrect.

Furthermore, if we do not stand by our medical colleagues, how can they on their own withstand the lonely if overwhelming pressures to function with responsibility, justice and professional honesty?

In the early 1900s, Dr. Sun Yat Sen, physician-founder of modern China challenged the oppressive power structures and championed improvement in the lives of millions of his countrymen, by spearheading independence from Imperial China. He believed that “physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.”

We must therefore, safeguard these staunch institutional values to the best of our abilities and commitment, so that we can be assured of our constancy with our medical brethren worldwide.

Our standard of quintessential professionalism can help conscientise our medical community, and enhance our common humanity. We can help remind our colleagues and our citizens that moral core values cannot be compromised, and that we are not alone in espousing these higher standards.

Caring Ethos
Having said that, as doctors, we must return to our Caring Ethos. We must regularly remind ourselves that among the professions, we are perhaps the only one that demands a caring value system. This has been called and imposed upon us from a long line of tradition, which spans more than 2,500 years. This is made personally explicit and binding when we take our Hippocratic oath, or its equivalent, when we graduate from medical schools, the world over.

Sometimes, who we are, and what we should be doing slips from our consciousness. These days, it is easier to regress into our baser instincts. Instincts, which appear to be all too human, yet perhaps, too influenced by and too fixated on the all-pervasive consumerist tempo of the free-market system.

We sometimes let our better judgement succumb to the demands and lure of lucre, of money, of personal and/or professional arrogance, which beclouds our inner voice, our true vocation.

Sometimes, we just get too immersed in the tedium of work and more work that we forget to reflect on this. We move along mindlessly, oblivious of the many forces that impact on our professional status, our gradually eroding if still circumscribed worldview.

Practice Issues
In the daily grind of routine—that heady pursuit of monetary gains, that overpowering ‘busy-ness’–we forget our healing art.

We distractedly dissipate our empathy, our special relationship with our patients. We lose that subtle touch of healing, that singular ‘intimacy’ with which we have been entrusted.

We let those “mystical chords of healing” slip away from us. We fail to harness and weave that innate physician attribute, that ‘shamanic magic’, which is by itself so powerfully therapeutic. Given with empathy, this special relationship may sometimes even supersede the need for medicines, intervention and the like…

Perhaps, it’s the overpowering commercialism so steeped in today’s medical practice, which has helped extinguish this sense of therapeutic healing. We are no longer admired as benign benevolent healers, but increasingly seen as purveyors of a commodity to be purchased…

Continuing Professional Development/CME
Nevertheless, we are called upon to do better—our patients expect this of us: to deliver safe, competent, and up-to-date care. Our regulators will soon insist on a minimum standard of continuing professional development and education.

It is estimated that perhaps only 10 to 20% of all practicing doctors ever bother with CPD programmes. A huge 80% out there, remain totally oblivious of the need to update themselves and their limited, possibly outdated medical knowledge.

We must choose to reverse this pathetic trend. In the revised Medical Act, this will address the statutory requirements for physician re-licensing, one that we will have to comply with, regardless…

Private Health Care Facilities & Services Act & Regulations (PHCFSA-PHCFSR)
As physicians, we have always been jealously proud of our autonomy and capacity to self-regulate. Alas, this is almost universally no longer the case. Rising costs and unsatisfactory service complaints have prodded policy-makers the world over, to impose more and more regulatory constraints on the medical profession.

By being apathetic, silent, uninvolved, uninterested, we have been overtaken by new laws, overweening managed care, litigation excesses, and lately painful new regulations which, seem to micromanage and even criminalise so many of the practice issues of private sector doctors.

Like them or hate them, the new regulations and laws are here to stay. But they are not benign: their sting has yet to be modulated despite our initial dialogue sessions with the MOH to smooth out the incongruities of some of these less palatable regulations.

It is because of these uncertainties and potential dangers of over-interpretation that we see these regulations as overbearing and unkind toward the private medical practitioner.

These are some of the modifications we have sought, which must be rectified quickly with the Minister and the officials of the MOH.

These must not be left to fester with uncertainty, to be overzealously interpreted and implemented by some enthusiastic practice division officials… We urge the Minister and his officials to help us resolve these as expediently and as justly as possible.

Medical Errors & Medico-legal Challenges
Medical mistakes are nowadays less and less tolerated or accepted by anyone—be they patients, their relatives or even our own professionals, and certainly not by the hovering predatory litigation lawyers.

The margins for medical error are diminishing every day; our patients’ expectations are growing, their demands for more disclosure mounting, and their endurance for medical mistakes or untoward outcomes, waning.

The recent end-2006 Federal Court adoption of the Rogers vs. Whitaker principle (instead of the physician-friendlier Bolam test) of adequate disclosure of material risk has placed a greater burden of proof of non-negligence on doctors.

There is that real danger that the judicial treatment of medical negligence issues may be extended more widely. The medical profession must vigorously oppose this possibility, because this would severely handicap our uncertain science and place us at grievous odds of difficult medical therapeutic options or decisions.

One way to help lessen this spectre of rising medical negligence is to stay current and knowledgeable. We must learn to constantly sweep away the cobwebs of old and outdated practices—we have to update beyond deeply rooted boundaries of rapidly obsolescent concepts.

But medical knowledge is not enough. We must communicate better. We must interact and discuss more comprehensively with our patients and their loved ones. We have to document that, procedures and risks have been well understood or disclosed. We must ensure that enough information has been expounded, before embarking on any medical or surgical procedure. No longer is it enough to simply push ahead paternalistic “doctor-knows-best” practices…

How else can doctors/physicians help maintain or advocate for a better image and trust from the public at large?

We must rekindle the Power of the Physician-Patient Encounter.
We have now more than 25,862 practising physicians in the country. If we estimate that each doctor interacts with at least 10 patients a day, this works out to some 250,000 doctor-patient contacts every day. Potentially this works out to some 7,500,000 physician-patient encounters in one month!

Thus, there are abundant opportunities to help present the unique face of the physician to our patients. If we present ourselves poorly, this will clearly leave unhappy and poor impressions, which will only sully our reputation…

Conversely, we can do much to enhance our image, our concern, our empathy, our caring nature—if we constantly remind ourselves that with each and every one of our patient encounters, we can have a huge and tremendous impact in helping to shape our kindlier face and profession.

We must make use of this power of engagement, this power to show our true professionalism and our altruistic best of what it means to be caring physicians.

Universal Healthcare Access: Lobbying and Advocacy planning/SIKK:
The MMA has always advocated for some form of universal access to health care for all Malaysians. Sadly after so many decades, this has remained a hotchpotch entity of a disjointed public-private mix—a variable partnership that is anything but sufficiently integrated.
Thus, gaps in access and failure to provide timely and affordable medical care, especially for more specialized tertiary therapies still bedevil our system.

There should be a better mechanism to address health care access in Malaysia. To be sure, no country has ever gotten this right, and every nation is still grappling with and tempering the excesses and the failures, to ease the public concerns about health care standards, access and its mounting costs.

The much-awaited National Health Insurance Scheme (SIKK) remains mired in the details and the implementation. The public is largely in the dark, and those who are concerned (such as Aliran, CAP, FOMCA and the Coalition Against Health Care Privatisation or Gabungan Membantah Penswastaan Perkhidmatan Kesihatan) have voiced very strong objections to its possible enactment.

These fretful focus groups pose several legitimate concerns, which should be addressed by any responsible authority. Questions about how to collect adequately, comprehensively and fairly, the premiums for such a scheme remain unanswered—which would endanger the community-rated contributions expected.

The exact nature of the roles of the private versus the public sectors following this new projected schema is also unclear.

The MMA is necessarily interested in this development, and has been offering its concerns and recommendations at various dialogues with the Ministry of Health. However, we too share many of the controversial points about its practicality at this juncture.

Perhaps as of now, the best approach would be not to overhaul the current system, especially when it is not yet broke! Perhaps, all we need to do is to tweak and fine-tune it to perform better!

Physician Remuneration
In this context, we have to acknowledge that our public sector doctors have had some success at attracting more reasonable salaries and perks, these past few years.

We thank the Minister, the DG of Health, the MOH and the PSD for agreeing to many of our suggestions to improving our lot. Tax exemptions and incentives have also been allowed which makes the take-home pay for public service doctors much more substantial.

We continue to urge for better remuneration and better service conditions for our sacrificing doctors in the public sector. Perhaps, with these enhanced benefits, public sector doctors can continue to serve more happily, rather than yearn to migrate to the private sector; the grass is not necessarily greener out there!

For the private sector however, there are still some public misgivings and disgruntled mutterings that doctors are over-charging, that medical care is too ‘expensive’.

Doctors’ professional fees have nearly always been misunderstood to be the main cause of escalating health care costs. This is far from the truth. Doctors’ fees take up some 15 to 45% of the total overall fees for various therapies/hospitalizations. However, mandated fee schedules now enshrined in the 2006 PHCFS regulations have served to control these charges.

As a medical professional, I make no apologies for our medical compatriots who do make money, with some doing very well indeed. This is the innate part of our human nature to wish, to want to do well of ourselves—we must recognize that this is indeed the ranking peak of Maslow’s self-actualisation.

Our professionalism, our top grades for competitive entry into med-school, our arduous and long training, our expertise and skills are often forgotten in the trade-off debate as to what is considered fair and reasonable wages.

At the same time, it cannot be denied that our fees for private care, when compared with those in the region have been nearer the lower end of the spectrum, and that insurance premiums have not risen to realistic levels required of our current status as a middle income developing nation.

Thus, this tussle for fair remuneration continues. The MMA will continue to champion a fairer deal for medical doctors as part of our legitimate representation for the profession.

That said however, the MMA also has a social responsibility to remind every doctor that the practice of medicine is not to be equated with other professions—we are imbued with that critical service tradition that necessarily mandates a greater expectation of altruism and benevolence and which marks us apart from others.

The fifth schedule of the revised MMA professional fees was completed in end 2008. We have passed this on to the Ministry of Health for its action to include this revision in the PHCFS Regulations. The previous fee schedule revision was last carried out in 2002, more than 7 years ago.

We are mindful that the current financial and economic meltdown has cast an ominous shadow over the state of the economy here as well as globally. Because of this, the MMA Council has in its wisdom and its social responsibility, agreed to delay this declaration of the new fee revision for the time being.

At the same time, we thank the Ministry of Health for seriously looking into updating this revised scheme and urge that these be quickly incorporated into the regulations, soonest possible.

Medical Education and Possible Glut of Physicians in the future
Dato’ Dr Abdul Hamid has already discussed at length the potential problems of uncontrolled medical colleges and graduates, and the potential for physician glut in the near future.

With 23 functioning medical colleges in the country producing some 1500 medical graduates annually, plus another 1000 or more overseas-trained doctors returning, we worry that there will be an uncontrolled glut where many medical graduates would be underemployed or worse, unemployed or poorly employed.

While we recognize that there is mal-distribution of doctor deployment to rural communities, we also fear worsening urban competition. As it now stands, in the KL-Klang Valley, the physician-people ratio is already 1:398!

Therefore, we need to be more pro-active in ensuring that the increase in the number of medical graduates be carefully modulated to accommodate the true needs of the population, the country.

But this may not be the only problem, as free trade agreements loom in the offing…

WTO/GATS/AFTA 2010.
We need to address the opening and freeing up of our health care services to ASEAN: AFTA, (ASEAN Free Trade Agreement) comes into force in 2010, i.e. in less than a year’s time!

Together with our increase in medical graduate numbers, employment and job opportunities for doctors would become even more challenging. The opening of the ASEAN market of freer movement of physicians and healthcare services is expected become quite unsettling.

Uniformity of standards and regulations should be considered to stem the unfettered influx of physicians of questionable quality or need. There is no doubt that there will be fiercer competition where many of our own homegrown doctors will be undermined, and their livelihood compromised.

Being a medical graduate will no longer be a sure thing for employability. Thus, we encourage our medical colleges to review their courses and standards, so that they can train medical graduates who can be world-beaters and at par with the best in the world, and not just jaguh kampung!

We also urge the government and Ministries of Health and Higher Education to review their objectives and policies vis-à-vis these changing supply-demand dynamics.

Flooding the market with medical graduates without due regard to their needed numbers or standards would be counterproductive when many of these may become unemployable, or who could only find other non-medical jobs instead. This would underscore the waste of having to undergo such expensive and rigorous training, in the first place.

Such precious educational resources could be put to better and more productive use—let’s produce doctors who would be practicing with pride as doctors, rather than become redundant and retrained as nursing personnel, medical representatives, administrators, etc, as has happened in some countries.

Closer Collaboration & Engagement with like-minded professionals and groups
Although the MMA represents some 8,201 doctors in Malaysia, two-thirds of all registered doctors still choose to remain outside our ambit. Notwithstanding this, their practices and livelihoods to some extent, continue to depend on our influence, our leadership and our actions.

I am aware that there are other like-minded medical and/or health advocacy groups out there. These smaller societies also represent somewhat more defined vested interests of some of our doctors; importantly these are not always mutually exclusive.

MMA does not and will not have the exclusive right to usurp the attention, the involvement or the representation of every medical practitioner.

We know that human beings are diverse enough to choose different associations to cater to their disparate needs and interests. These are as legitimate and as forcefully influential as their leaders would have them be.

Some amongst our MMA members have expressed dismay that there should be other societies out there who appear to duplicate our function and our purpose. They feel that these smaller groups would dilute our common purpose and distract our rightful attention to detail.

However, this wish to exclude others in the same medical profession who choose to be more active elsewhere, is misguided in my view. We should work towards more inclusive and collaborative positions of cooperation and consistency of objectives. Most importantly we should work towards a final common good for physicians as well as for our patients.

Let’s face this honestly: some of these medical societies do have some very dynamic if narrower interest bases. They obviously represent some of the urgings and intentions of some of our other doctors, because of their ability to deliver on certain issues relevant to their perceived interests and benefits.

Each society has its own strength and occasionally its own singular expertise, which may complement or even exceed our own MMA’s collective vision, action or inaction.

Instead of shunning these groups as competitors, we should be more generous and magnanimous. I strongly believe that we should harness all these strengths to enhance our capacity as a more comprehensive and complete front for our shared bargaining lobby with the authorities that be.

Under my leadership we will engage these groups more closely and work with them to further our professional agenda and interests, and I believe ultimately we will also boost our patients’ wellbeing and benefits.

Therefore, the MMA under my leadership will engage meaningfully with the Federation of the Associations of Private Medical Practitioners of Malaysia, the Association of Specialists in Private Medical Practice, the Islamic Medical Association, Malaysian Pharmaceutical Society, Consumer Groups, Coalition for Healthcare Initiatives, Association of Private Hospitals of Malaysia, Physicians for Peace and Social Responsibility, Human Rights Advocacy Groups (including SUHAKAM, Suaram, HAKAM), and the Bar Council on issues which we share or have common grounds to pursue.

Paramount Importance of Engaging & Collaborating with MOH
Needless to say, we must engage and work closely with the Ministry of Health and its officials on issues which pertain to and embroil the medical profession and its members, as well as our rights and responsibilities vis-à-vis our patients. We note that 15,862 doctors are working within the MOH, while some 10,070 doctors are in private practice, as of 31 Dec 2008 (data from Dr Wan Mazlan, MMC Secretary).

We wish to reiterate that we have had some excellent working relationship with the MOH on most issues pertaining to the medical profession. However, whilst many of the issues pertinent to public service issues have been satisfactorily resolved and are regularly engaged in collaborative progress and dialogue, issues with regards private medical practice have been less collegial and/or agreeable.

In particular we are extremely heartened that promotional aspects in the public sector have been tremendously improved, with almost a hundred senior doctors having been promoted to JUSA C and above—we wish to record our sincerest thanks to the DG of Health, YBhg. Tan Sri Datuk Ismail Merican, for putting his personal touch, and commitment to help bring this about. We fully acknowledge his positive input to help our Health Minister make important and gracious gestures toward our medical fraternity and our interests. Thank you Tan Sri!

We understand the constraints and his singular commitment to enhance the standards of healthcare in the country, and we fully support his conviction and his passion.

But alas, while well intentioned, the means toward this end, is sometimes fraught with contrary approaches, which lead to conflicting interests among various stakeholders, with the medical doctors sometimes receiving the shorter end of the stick. This, we must admit have sometimes created some friction between the MMA and the MOH.

We will try very hard to mitigate such differences in styles and work toward closer cooperation and ultimately for the greatest benefits to everyone, including physicians! Thus, while we cannot always agree with all the purported MOH policies and plans unreservedly, we will continue to share and contribute our ideas and expertise to establish a better healthcare system for Malaysia.

As a vital bulwark against unseen or unforeseen practical professional problems, the MMA will shoulder its balanced responsibility to help guide and shape some of these plans and policies in a manner that agrees with our objectives and that of our patients’ and physicians’ interests.

Although we have in the past been quietly, successfully working towards greater physician benefits, these have not always been understood by doctors out there, who perceive that we have been too silent, too slow, too unresponsive, perhaps too submissive.

It may be because of this negative perception that the MMA has not been able to attract more membership and support, of late. Thus, I do believe it is time to raise our noise level, to be more engaged, so that our standpoints can be better appreciated.

Under my leadership style, I have campaigned on being more vocal and more engaged in physician and healthcare issues, and this I intend to carry out as promised. Therefore, the MMA under my watch will be more resolute and will be more vocal.

This is not to say that we will be arrogant or unreasonable, but it is important for us as a medical body to articulate our viewpoints and our convictions more clearly and perhaps, more publicly.

I believe that under our current sociopolitical climate of greater participation and expectation, our doctors demand this—doctors are urging for a greater voice and say.

Therefore, we will not be too fearful of putting our viewpoints across if these are believed to be the best solutions for our healthcare system.

We will cooperate where we share common ground, but we will also not be too afraid to disagree where such decisions and regulations impinge upon our practice and our livelihood. We will of course not bend our principles simply for our own narrow professional interests per se, but will make measured responses of workable and practical solutions, which benefit above all our patients’ interests, without betraying our own.

Where physician professionalism and autonomy are threatened, we will voice our concerns clearly and earnestly so that we remain relevant and consistent with the tenets of global medical professionalism and ethical practices, and as a member signatory to the World Medical Association and the United Nations.

If we show greater leadership, then I believe others would also agree to be part of our show and strength of purpose. If on the other hand, other similar societies are more dynamic and innovative, then we should not be too proud to acknowledge their strengths and leadership—we must work towards a win-win partnership to attain our greater common goals.

We must share a more inclusive attitude with all who wish to join us in enhancing our medical professionalism and practice. We must refrain from excluding membership participation just because of minutiae and trivial differences. This will instead turn away many who would have joined our forces to move in tandem within the MMA. We lose membership gain and possibly too we lose our legitimate representation based on strength of numbers.

Therefore, we must work harder to show that we can still attract our younger physicians to join us. We must show that we are still relevant—that we still have a greater purpose of policies and influence, within which our new members can take greater pride of place.

We cannot afford to simply be disagreeable for disagreement’s sake. We cannot afford to remain a close-looped fraternity, only looking after our diminishing membership—we must become more representative and attractive. We must move forwards. We must show greater leadership of purpose and determination.

Concluding Remarks
I believe we can and we must be bold enough to change, to believe in the art of the impossible…
US President Barack H. Obama (in is Inauguration speech, 20 Jan 2009) said, and I quote:

“… that greatness is never a given. It must be earned. Our journey has never been one of short-cuts or settling for less. It has not been the path for the fainthearted—for those who prefer leisure over work, or seek only the pleasures of riches and fame. Rather, it has been the risk-takers, the doers, the makers of things—some celebrated but more often men and women obscure in their labor, who have carried us up the long, rugged path towards prosperity and freedom.”

Each and every one of us has that little something that we do, most of the time obscurely and outside the mainstream of our consciousness or attention. We carry on in our mundane labors, the best that we can, quietly and with dignity.

As medical professionals we can do no less. Indeed, we are called upon to do even more. Let’s make our profession even more luminous as we enter into the new century. Allow me to paraphrase yet another segment of Barack Obama’s inaugural message:

“The time has come to reaffirm our enduring spirit; to choose our better history; to carry forward that precious gift, that noble idea, passed on from generation to generation.”

How aptly these words reflect the profession of medicine!

Let us practice the noble art of medicine as has been enjoined upon us from time immemorial!

Let’s engage more meaningfully and help shape the kind of medical practice that we’d all be proud of.

Let’s find ways to ensure that healthcare is not simply an unreachable luxury only for the privileged few, but one that every Malaysian citizen can access without barriers.

Let’s work to find common solutions, which will benefit all, but especially those in need, i.e. our less-well-of or uninsured patients.

Let’s work towards a common system where healthcare is not splintered and dichotomized among those who can afford and those who cannot.

There is much that needs to be done, and more that should be considered and thought about.

Let us doctors and the MMA concern ourselves with more and more of our actual medical professional issues, instead of being bogged down in enervating trivialities of administrative lapses.

Let’s remind ourselves what philosopher-ethicist James Q. Wilson had said, that:

"Mankind's moral sense is not a strong beacon light, radiating outward to illuminate in sharp outline all that it touches. It is, rather, a small candle flame, casting vague and multiple shadows, flickering and sputtering in the strong winds of power and passion, greed and ideology. But brought close to the heart and cupped in one's hands, it dispels the darkness and warms the soul."

~ James Q Wilson, in The Moral Sense, 1997, p251. Free Press Paperbacks, NY.

Finally, I would like to paraphrase Hilary Clinton: “We'll have some ups and some downs. We'll face some obstacles along the way.” Let’s rise above parochial interests and work towards achieving our collective objectives.

Recent challenges and setbacks for the medical profession should not cause too much despair and despondency for doctors. Our own controversial administrative crises should not dampen our spirit of resilience and strength.

On May 24, 2009, Catholics celebrated World Communication Sunday. Pope Benedict in his message for that day said, and I quote

“Life is not just a succession of events or experiences: it is a search for the true, the good and the beautiful. It is to this end that we make our choices; it is for this end we exercise our freedom.”

Finally, I’d like to leave you all with this Chinese saying:

“Let’s wake up the earth from lethargy! When winter comes, can spring be far behind?”

(Interestingly, William Shelley had also written almost an identical ‘Ode to the Wind’: “O Wind, if Winter comes, can Spring be far behind?”)

I thank you for your patience, indulgence and kind attention!

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Kugan’s Autopsy Findings & Inquiry: Unsettling Questions remain

It is laudable that the Ministry of Health had taken the preemptive move to help diffuse the public anger regarding the custodial death of Kugan Ananthan, especially in the light of discrepancies between two separate post-mortems.

Whether an inquiry initiated on its own behalf is the correct avenue to address the public unease about this custodial death, is open to differing interpretation, acceptance or otherwise.

Any inquiry if it should be made at all should be carefully-constituted, thoughtfully empanelled and well-empowered by law. Its terms of reference must be made absolutely clear. It must uphold the final truth.

It must be based on facts and rational analyses of findings which are consistent, and which should be striving towards the ultimate truth of what actually is the cause of death or its contributing factors.

It should not be simply to water down discrepancies which would need fuller explanation and perhaps further elaboration from the actual forensic pathologists who had performed their respective tasks. These pathologists should be allowed to defend their findings and interpretations.

Furthermore, more expert and renowned forensic pahologists should have been invited to give their interpretations as to the facts of the findings and their weightage of causes of death, especially since there had been unmistakable evidence of torture, i.e. undeniable beating marks and unexplained bruises. These experts should be fiercely independent and thus unimpeachable.

Most importantly, this inquiry held behind closed doors, should not be seen to be papering over any misdeeds of any authority which it may be perceived as trying to defend.

Also, since this is not a public hearing and we know that the second pathologist declined to take part in the inquiry, this may make the report less than solid or above reproach. Seniority of pathologists is no measure of professional competence. Forensic evidence based on previous precedents and specialist experience, and not conjectures should be the essence of any meaningful truth-finding exercise.

It is usually disingenuous and pointless to assume another chance event as having taken place to be the cause of death, just because it is possible. Suggesting the unlikely pathologically-unevidenced diagnosis of acute myocarditis is arguably simply a guesstimate. Whichever is more probable and plausible is usually the truth, to paraphrase the legendary Sherlock Holmes.

Unfortunately, because of these glaring slants to the report, questions will continue to linger as to whether this report is truly independent and whether all the inquiry members are in agreement with the findings.

The legal standing of the report is still questionable, and may be challenged in a proper court. It might be better to have a public inquiry where all queries and representation can be made known to the satisfaction of the public, and especially, the victim's family.

To add salt to injury, doctors are aghast and very alarmed that the police had raided the UMMC pathologist's office and taken the material records of his autopsy findings. We are also shocked about media reports that tissue samples for toxicology from the second post-mortem, which had meant to be sent to an independent laboratory in Australia had been intercepted and seized by the police. We certainly hope that this is untrue.

Toxicological studies should always be allowed to enable proper and independent discovery of the truth. Denial of such a legitimate avenue for forensic finding would prejudice against the police, and make their action that much more difficult to accept or to tolerate.

Moreover, this arbitrary seizure of the pathologist's medical records from his office in UMMC, is reprehensible, unprecedented and certainly breaches normal procedures of medico-legal discovery. Usually only detailed reports are obtained from court-approved injunctions and demands.

Medical records and details are nominally the property of the physician in charge or the facility where he practices, and should only be made available under a court order, and are usually never confiscated or seizable by any enforcement authority.

There are clear procedures to be followed, and are well articulated in handbooks for the police and enforcement authorities, clearly established by the UN Center for Human Rights. I'd like to reiterate that: "International humanitarian law prohibits the following acts in all situations:

- murder;

- torture;

- corporal punishment;

- mutilation;

- outrages upon personal dignity;

- hostage-taking;

- collective punishment;

- executions without regular trial;

- cruel or degrading treatment."

Such extrajudicial actions should never be made in a climate of intimidating circumstances just because these events may mar the good name and professionalism of the police force.

It is difficult to comment on the public-worthiness of this inquiry, the 10-member panel of which incidentally incorporated 2 foreign forensic specialists. At best this inquiry had added to the confusion of being a third interpretation into this sad case of custodial death but it did little to refute the probability of torture and its possible link to the death of the detainee.

Any custodial death in any instance the world over, is inexcusable, wrong and criminal. The UN Human Rights Committee has defined "Extralegal, arbitrary or summary executions as deprivation of life without full judicial process, and with the involvement, complicity, tolerance or acquiescence of the Government or its agents. This includes death through the use of excessive force by police or security forces."

Torture is further defined by the United Nations Human Rights Committee (UNHRC) and its Committee against Torture (CAT) as: "Any act committed with intent to cause severe pain or suffering, whether mental or physical, for purposes such as: (a) obtaining information or a confession; (b) punishing, intimidating or coercing."

Therefore, torture of any one suspect or detainee or prisoner is never condoned, whether this leads on to death is immaterial (but which only adds to the grievousness of the crime), and is liable for prosecution in any international court of law.

Kugan's custodial death and other possible past custodial deaths should be given a truly independent investigation by a publicly open Royal Commission or Inquiry or even by SUHAKAM.

It is time that we adhere to humanitarian principles as we grapple with our modernisation to become a developed people and nation. Our human development index as a civilised nation must necessarily rise proportionately.

We call on the police and law enforcement agencies to respect these tenets of modern life and human rights and urge them to abide by these nondiscriminatory rules as a norm. Only then, can we believe and respect their true and usual professionalism again.

Doctors must be Vigilant when dealing with unexplained Custodial Deaths

Any custodial death must always be considered circumspect and should invite close and meticulous scrutiny as to the possibility of foul play.

The custodial death of Kugan Ananthan therefore, is very worrying and needs full explanation and disclosure to the satisfaction of all fair-minded Malaysians. That this is one highly publicised case among the many other custodial deaths (1,535 from 2003 to 2007!) in recent history of our Malaysian police detention centres, must alert us to the possibility of a sustained if tacit condonement of such practices by the highest echelon of our police or even government authorities. See Dr RS McCoy's article " Kugan's death a reminder of systemic weaknesses".

No matter the circumstances of detention, every prisoner or detainee must be accorded his/her human right to be treated justly. He or she must be presumed innocent until proven otherwise in an independently constituted and respected court of law.

Because history is replete with such cynical and abhorrent cases of torture leading to custodial deaths under various authorities, it must always behoove doctors that they owe it to humanity to expose these heinous acts so that we can help prevent their continued recurrence.

It is useful to remember that despite the furore of recriminations against the Abu Ghraib and Quantanamo detention centres, the number of custodial deaths following the Afghanistan and Iraq wars, from 2001, did not reach such numbers as have been acknowledged by our own police force. (See Steve Inskeep "The Question of Torture")

Timely reminders to physicians have been shown to alert them to the dangers and possibilities of slipping down the slippery slope of expediency and collusion with authorities in such repugnant but illegal activities involving torture to extract information or forced confessions.

There can be no clearer mandate than that expounded by the World Medical Association (WMA). In its 1975 Declaration of Tokyo, which describes guidelines Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment, the first article states explicitly that:

"The physician shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty, and whatever the victim's beliefs or motives, and in all situations, including armed conflict and civil strife."

Therefore, it must always be in the forefront of any physician or forensic pathologist's mindset that he or she must exert his/her full medical professionalism to the best of his/her knowledge and experience, without fear or favour. Of course, this is not to say that many or most doctors willingly adopt such timorous or subservient attitudes just to be on the 'right' side of the law.

It is generally recognised that in authoritarian or autocratic states, physicians can find themselves in very difficult circumstances of having to consider their own personal or family's safety and self-interests. There may be genuine fear of repercussions, harassment or threats which can and indeed had occasionally been shown to intimidate physicians who had conscientiously written medical reports which are opposed to the expectations of certain authorities.

Notwithstanding these possibilities of threats, the physician must undertake to serve out his function and duty, without falling victim to such fear and intimidation. Every physician who acts righteously will always have the strongest and most vocal and concerted support of all his fellow physicians the world over! The WMA and the MMA together with other human rights proponents including the UNHCHR (United Nations Office of the High Commissioner for Human Rights) will always stand with the physician—i.e. he or she is not alone.

Thus, being physicians, there can be no compromise: we must abide by our rigid codes of professionalism and medical ethics to put such personal interests aside in favour of our patients, and in the case of the deceased, our unbending duty to determine the forensic truth as to the cause or causes.

When anyone dies, especially unexpectedly, the cause of death must be ascertained with reasonable certainty, so that there is closure and acceptance from their loved ones and society. Forensic pathology's dictum is that it must serve as the ultimate arbiter to provide the concluding proof of science of the final truth, the final diagnosis... (See Role of pathologists in human rights abuses)

In fact, one should endeavour to go overboard to prove that no criminal action had led to the unexplained death of anyone under detention. To be too ready to attribute to natural causes when there had been overt signs which cannot be explained, can lead to accusations of collusion to obstruct the explication of the truth.

Most importantly, doctors must not allow themselves to be persuaded or intimidated by the authorities to facilitate favourable but inaccurate reports, just to placate the illegal actions of the police or military or any other persons who had so callously disregarded their responsibilities as purported guardians of law enforcement in any country.

It is understandable that clinical role conflicts between duty to the state and to the patient sometimes arise. However, there is no compromise as to where our physician duties lie: i.e. our patient's welfare must take all precedence, and "undivided commitment to patients is the sole guidepost for clinicians who face conflicting expectations." For the physician the importance of clinical fidelity is of the highest moral and ethical standpoint which should and must not be compromised. (see M. Gregg Bloche "Clinical Loyalties and the social purposes of Medicine", JAMA. 1999;281:268-274)

Attempts to subvert the truth or to cover up illegal acts are not only unethical and unprofessional but also lends such actions to possible criminal prosecution as colluding to condone torture and abetting homicide.

The World Medical Association will support, and has encouraged the international community, including all national Medical Associations and fellow physicians to support, the physician and his or her family in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment.

As physicians we will all stand with the doctor under threat—the world community is watching and will support earnestly the clinical rectitude of any doctor so implicated, if or when he or she acted in an ethically correct manner.

However, the converse is not true, we cannot and will not support any physician who choose to act to condone or cover-up any police action or actions which are cruel, inhuman or degrading, especially when this leads to death.

Unfortunately in this country, there is no mechanism to quickly look into or investigate such suggestions of medical misconduct, if indeed that is the case of the custodial death of Kugan Ananthan. As our Medical Act now stands, we still need an official complainant for us to initiate proceedings against any medical practitioner, and this will still take some time to be fairly and fully completed, even if given expedited pace in the public interests.

Nevertheless, in the light of such widespread publicity, the Malaysian Medical Council will have to be very wary not to be seen to be colored or prejudiced by public opinion, but to be as fair and just to all parties concerned, with only its necessarily circumscribed focus on what is deemed medical professional conduct or misconduct.

Thus, it is premature and unfair to expect instantaneous conviction and/or to pass judgement as to whichever aspersions of misconduct that has been cast on the first pathologist in the light of conflicting reports from a second. Differences of opinions alone cannot be the basis of professional misconduct, unless it can be proven beyond reasonable doubt that the physician concerned had unethically colluded with the law-breakers to cover-up such a dastardly act as torture and finally the unexpected death of a prisoner under detention.

For the unfortunate case of Kugan Ananthan, we will have to let the courts decide on the exact nature of his untimely death, and let all fair-minded people determine the merits or demerits of the two conflicting post-mortem reports. Dissatisfaction with whichever report or action by any medical practitioner can only be reported and lodged with the Ministry of Health and the Malaysian Medical Council, and let due process take its rightful if tardy action.

For whatever it is worth, this unfortunate but highly-publicised custodial death has put on notice that the police or any authority for that matter, cannot expect a free ride to do as it pleases with impunity.

Our rakyat demands that this cannot be allowed to recur, and that we all expect retribution or answers on those who so callously take another's life, under the guise of duty of law enforcement. The dignity of our Malaysian citizen must not be brushed aside so coldheartedly any more.

I'd like to end by paraphrasing M. Gregg Bloche's concluding remarks, that "by making a strong stand for clinical fidelity, ethical medicine in Malaysia can reanimate its sense of purpose and promote those facets of professional autonomy likely to contribute to the common good. In so doing, physicians might also contribute modestly to reducing the insecurity and incivility that appears to be escalating in Malaysia, fed by repeated collective experiences of breach of faith."

Our rakyat demands and deserves more, our rights have been awakened! Physicians must stand unequivocally on the side of progress of human rights and an unshakable and respected medical professionalism. Our authorities and police force should aspire to do the same.

A slightly abbreviated version appears in malaysiakini on 11 March 2009, Physicians must be more vigilant