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.

MMA vs. MMC: Don't muddle their roles

MMA vs. MMC: Don't muddle their roles

David KL Quek, malaysiakini, 22 Dec 2009, 11.08am

comment I sense great disquiet and anguish that many doctors appear so helpless in the wake of several issues which appear to have emasculated the medical profession and make the practice that much more onerous and perhaps a tad nit-picky.

I will not touch on the political slants and the many possibly hearsay implications of one writer's perspective regarding the director-general (DG) or ministers of health, past and present. That is his right.

However, it must be clarified that the Malaysian Medical Association (MMA) is not synonymous with the Malaysian Medical Council (MMC). The MMA does not form part of the MMC and does not have any influence on it, or vice-versa.

The MMA was formed nearly 50 years ago to represent the interests of the medical practitioners. Our motto reads Jasa Utama which translates into 'Service First'. This necessarily implies that our interests must rest with our service to our patients first and foremost.

Conversely, the MMC is the regulatory body formed by an Act of Parliament, which governs the spectrum of medical practice, including formal registration of all medical professionals, as well as meting out disciplinary action against errant doctors, after due processes of inquiry, fully enshrined in the Medical Act 1971.

Every country (and some states in the US) has such a governing disciplinary board or council, because professional matters can become contentious and sometimes tinged with poor and unethical practices, which we call 'professional misconduct'.

Of course, no doctor would like to be hauled up for inquiry into professional conduct, because this process can be very unnerving and stressful. Their jobs and right to practice are literally on the line.

In every profession, there will always be those who come perilously close to the edge of propriety in their dealings with patients. This is especially so in the usually quite asymmetric patient-doctor relationship, where faith and trust in the doctor clearly is more one-sided than the other way round.

The MMA also operates on an independent code of ethics. It deals with complaints about errant doctors from the public and occasionally from our own doctor members. We do not actively search for possible wrongdoing by doctors. But we owe it to our patients to help answer some of their grievances, which may have an ethical basis or misunderstanding.

The ethics committee conducts investigations, which include asking the doctor involved to help answer the charges - there is always a right of reply, where even the right to engage legal counsel is allowed. The complaints are then resolved amicably, or are referred to the MMC if no agreement is reached.

Previously the MMA has taken the role of complainant against errant doctors at MMC hearings, but these days we have tried to persuade the complainant to directly represent him or herself for greater clarity and purpose.

Referral to the MMC for further action or possibly a full inquiry is based purely on what we consider to be possible breach of professional conduct, but not medical negligence. Professional misconduct has more to do with the medical profession's expectations as physicians under our Code of Ethics. It has no legal basis, although the connotations are as ponderous.

Every doctor understands his or her ethical boundaries, which are clearly spelt out in several documents either by the MMA or the MMC (Code of Professional Conduct). No doctor can claim this is an archaic practice and thus choose not to abide by these, otherwise, he or she has no right to continue being a part of the profession which has survived since the time of Hippocrates.

You may not like these ethical constricts, but you will have to toe the line, to protect both our august profession and more importantly, the patient and the public at large.

MMC decisions

The fact that I have been elected as a MMC member since 2004 is not exactly a secret. I was elected as one of 11 MMC members by all Malaysian registered doctors, and not just by MMA members - although only about 15-20 percent actually exercise this right through a nationwide postal ballot.

Some of the elected members have been re-elected for many terms because these doctors are stalwarts of the profession. They are respected by almost every doctor as holding the profession in its highest regard and to the best standards. One senior clinician and past president of the MMA has been an elected MMC member successively (every three years) for more than 25 years.

The DG of Health is president of the MMC under the Medical Act, while the other members are appointed from the universities or the Health Ministry.

As councillors, we generally have the interests of medical doctors and professionalism at heart, but our foremost role is to protect the rights and interests of patients. We cannot be and are not just blindly partial toward protecting our 'own kind' so to speak - that is not our remit.

Conversely, it is untrue to imply that the MMC is bent on arbitrarily punishing doctors for trivial issues. Legal representation is almost always encouraged and due process always given extended leeway to arrive at the truth of every dispute.

A minimum of nine councillors must be present to form a quorum to decide on any full inquiry, which is a form of jury of our peers. A decision to sanction or to acquit any doctor is taken very seriously and only after much discussion and debate, as well as an internal discourse with our own conscience, experience and moral underpinnings.

Most decisions are made by majority vote, but very often on unanimity, which underscores the commonality of purpose and ethical compass, which everyone pledge to perform as MMC member. We all understand the seriousness of our collective decisions. Making a decision is not at all a frivolous exercise of misguided power play, as implied by the letter writer.

Although some MMC findings have been overturned by the High Court due to procedural lapses - long delays and more rarely, misunderstandings on exact expectations of legal interpretations - the MMC as a regulatory body stands by its collective disciplinary decisions.

The decisions are, by and large, representative of quite serious misconduct applicable to doctors the world over, such as causing harm due to callous disregard to one's training and expertise; yes, employing unregistered persons to act as 'doctors' in helping to run their clinics; dishing out drugs without seeing or examining patients; or sometimes acting as high-class drug pushers for drug addicts; or selling medical chits.

Please don't confuse the MMA with the MMC. The MMA does not have the power to suspend, deregister or to reprimand any doctor under the law. We may however, help facilitate some complaint mechanism for further action.

Middle path

The MMA has already expressed dismay about the 1Malaysia clinics to be run by medical assistants instead of doctors. We are taking steps to see how we can influence its unwelcome direction. Although we understand that this may be a preliminary step - just 50 clinics in urban areas, this move may be a starting point to further extend this exercise, which will demoralise the profession of doctors, and worse would undermine the standard of health care for our less- than-informed rakyat.

We are working unfortunately behind the scenes to try and ameliorate its fallout, failing which, some greater collective action may be called for. Holding an EGM or conducting signature campaigns or even protest rallies may be just some of the options that we may contemplate.

We are likely to begin with a signature campaign to enlighten the ministry and the premier that most, if not all, doctors are really opposed to this move. However, it is clear that different doctors will see different actions as appropriate, while others will not. We will still strive for a middle path.

Unlike the British or German Medical Association, the MMA was not registered as a trade union, and thus our approach cannot be the same. Nevertheless, the MMA has been acting as a de facto professional body, which does look after the welfare and the various benefits for our members and doctors.

Most of the many perks, wage gains, overtime reimbursement, and promotion prospects of public service doctors have been won through the arduous efforts and campaigns led by the MMA, through its Section Concerning House Officers, Medical Officers and Specialists. Clearly we cannot have everything we want to be accepted wholesale, by any authority, let alone the government.

We have been successful in many ways, but weaker in others such as private GP concerns. This may be because many GPs choose to be rather apathetic and reactive unless issues impinge upon their practices.

Most GPs also are disjointedly single-minded, and not as cohesive as the public service doctors. We recognise some of these weaknesses and are working hard to rectify these so that we can be better represented at crucial dialogues with the ministry and the government.

With regard to doctors being able to pool funds to protect their rights, this is a fool's paradise! We have problems even asking doctors to be members of the MMA, when our annual dues are just below RM300.

When we finally looked into our membership rolls (previously more than 13,000), we had to delist some 4,000 doctors for defaulting on membership fees. We now have 8,200 members in benefit, from a total of around 27,000 registered doctors as at 2009.

Go figure! How strong can we be when most doctors are only interested in their own narrowly prescribed world? And no, there is no compulsion for any doctor to be part of the MMA, unlike the Bar Council (all lawyers are mandated to be a member), although this may be the way forward should the government accede to our request to bring this about!

The German and some western medical associations are compulsory for all registered doctors, and their fees are usually commensurate with their status.

Under such constraints, of course, the MMA is doing its best to cope with all these challenges, which will differ in style and approach with every leadership. My own position is to engage and influence without fear or favour.

But on the surface, this is harder to appreciate because contrary to what many members choose to perceive, not all or any of our press releases or communiqués are likely to see the light of day. We do not control the media, and neither can we control their prerogative to publish or to slant their headlines.

Under the best of circumstances, the mainstream media and the authorities may choose to ignore the best of our intentions. But plod on, we must, and we do the best we can.


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

Moments of Madness…

"A disciplined conscience is a man's best friend. It may not be his most amiable, but it is his most faithful monitor." ~Henry Ward Beecher (U.S. clergyman, 1813-1887)

"The shortest and surest way to live with honor in the world, is to be in reality what we would appear to be; all human virtues increase and strengthen themselves by the practice and experience of them." ~ Socrates (Greek philosopher, 470-399 B.C.E.)

[Some 2 years ago, I wrote an editorial on moments of madness following the infamous head-butting by football superstar Zidane, which had been coined a 'Zizou' Moment. I think it is good to review the principles of that message today...]

Possibly 2 billion people viewed the World Cup finals early Monday morning (10 July, 2006, in Malaysia) riveted by perhaps the most memorable incident of the entire month-long orgy of soccer extravaganza. French football maestro ‘Zizou’ Zidane head-butted Italian agent provocateur Marco Materazzi in what must count as the most inexplicably perplexing act of the tournament.

Notwithstanding whatever the provocation, that loss of control, that one moment of madness must forever be etched in the psyche of Zidane, as one final act of regret, which has blemished the demigod-like status of perhaps the most remarkable playmaker of soccer the world has ever known over the past twenty years.

What happens when one finally snaps may never be totally explained, nor can we ever hope to finally comprehend how or why it had taken place. Volumes have now been written about this indelible incident, and I do not wish to add to psychoanalyzing the whys and the wherefores.

This ‘Zizou’ moment however has been dissected and interpreted in several ways. One most recurring theme is that of justifiable violence/retaliation, taking the law into one’s own hands when provoked, when criminal acts or even insulting verbal or physical gestures are directed against us, when we feel that our honour has been tarnished.

It harks back to faintly-remembered times when lawlessness abounds and we the helpless wretched citizens cannot depend on the authorities or law enforcement agencies to deter or to take action against these perpetrators of wrong-doing. Thus, this wrought-up sense of unquenched frustration and blinding anger had swung many toward some form of vigilantism or justifiable retribution, which seems to have become more acceptable, but which in every civil society we have always resoundingly frowned upon.

Personally, I am of the opinion that physical violence and reprisal is never justifiable and that this can only amplify tensions toward an escalating gratuitous and senseless denouement, where innocents become embroiled and are hurt or slaughtered without rhyme or reason.

Consider the rising violence and tension in Israel, Palestine and Lebanon, and the potential for wider conflict in the Middle-East. Truly, as had been so well expostulated by Mahatma Gandhi decades ago, “An eye for an eye would make the whole world blind”!

I want however, to address here the more common moments of madness, the careless thoughtless actions which we sometimes act out, unthinking yet irreparable and irretrievable: small oftentimes silly acts which thankfully do not cast huge imprints or sequelae which can change, cripple or endanger someone else...

Most, if not all, are miniscule in their impact and are forgotten almost as quickly as they are committed—perhaps our ‘venial’ sins, our little ‘white lies’.

Sometimes however, these little acts become inured and acceptable, when they are repeated often enough to become subterranean habits or subconscious patterns of behaviour, which harden the insensate and Dr Hyde-like aspect of our other selves.

As doctors however, these may have been inadvertently but unprofessionally negligent, dangerous or even lethal to our charges, our patients, but we have become just too anaesthetized to recognize their gravity, their presence even.

Yet in rare instances some or even just one of these may have implications, which can be life-changing, life-defining or even catastrophic. Pleading in hindsight, with simplistic statements that we were just being human and had been pushed to the edge of our tolerance and control unfortunately, does not make this any better or justify its severity or gravity.

Consider some of these common instances of shame, these moments of weakness, of madness even:

• taking unfair advantage of our gullible but frightened patients by suggesting urgent but unnecessary tests or therapies;
• preferential referring to our doctor friends or hospitals who promise some kind of kickback;
• dishing out supplements because our patients urge or apprise us about their preference for alternative medicines;
• deceiving or defrauding our patients by inducing them to take part in some financial deals because of our special doctor-patient relationships;
• submitting to our baser self by engaging in sexual liaisons with our patients or their partners;
• choosing a convenient career path to become high-level drug-pushers by indiscriminate selling of hypnotics, sedatives, cough mixtures to drug addicts;
• selling medical certificates for a quick buck;
  
• becoming serial abortionists because there’s money to be made; etc…

We would all be remiss if we do not animadvert on such acts, which are growing more common nowadays.

Are these baser instincts simply trivial moments of madness? I beg to disagree, but no, these are not momentary lapses of conscience or behavior, they are consistent patterns of ethical breaches, which should be loudly denounced. They are definitely not conduct becoming of a medical professional.

Are they occurring more frequently than we have recognized? Sadly, perhaps so. Are they simply the work of a tiny segment of our fraternity? We certainly hope so, that these are the fringe numbers which bring shame to the profession and are unfortunately tarnishing our good name with their very thick brush strokes of professional delinquency.

Nevertheless, there are other possible moments of weakness that rarely can afflict the medical doctor. These uncommon out-of-character and enigmatic errors are often one-off, but may sometimes be extremely serious and egregious, and then become ethical challenges, which have to be scrutinized.

These are moments sometimes squeezed and secreted out due to tremendous pressures of internal conflict. Pertaining to these, we must be very resolute in our self-restraint and be extremely mindful so as to maintain our innate sense of proportion, our professional ethics.

There is unfortunately for us as doctors, very little hope of retraction or turning back, once these actions are set in motion or are enacted out to the full, and we would have to face all the attendant consequences and possible sanctions.

But this is one human dimension which doctors could perhaps be better understood from the public and the governing/regulatory authority perspectives.

Because of our lofty position in society—our innate and traditional trustworthiness which the public has endowed upon us—we are often placed in an unreal pedestal of pre-eminence, which may not always be in our best interests (and certainly not in our patients’ either!), and which are often too high and haughty for us to sustain continually as fallible human beings.

It is true that as doctors we welcome even relish such respectability. Sometimes we deceive themselves that we indeed deserve such supercilious placements and snobbishly surround ourselves with such arrogance that we fail to see our humanness, our human frailty and our foibles.

But any thinking person, much more so because we are doctors, will concede that we are all imperfect and will make mistakes; that medicine is altogether more of an art (with more uncertainties than we can imagine) than an exact science that we would want it to be—whatever evidence-bases there may be to embrace and ratify.

We doctors have differing standards of practice, experience and perceptions, largely because of the multitudinous medical colleges and training that we individually have passed through. We are also of disparate personalities, which range from the benignly empathetic Dr Marcus Welby-type to the arrogantly cocksure Dr Christian Barnard-type.

We range from the placid, contemplative doctor to the brash, trigger-happy knife-wielding surgeon or catheter-brandishing interventionist, willing to try out any medical procedures or therapies whether they are experimental or just because they are simply possible.

Let the devil in the details look after themselves, benefits or harms are immaterial and does not immediately concern us in the near term… Our patients become our playground, our artistic canvas to create and display some of our audacious skills and derring-do prowess… Some of our patients may fare poorly, but some may also do superbly well, often in spite of us and our actions, or our lack of it.

Some newfangled techniques have actually been discovered from just this type of intrepid cutting-edge experimentation and hit-and-miss try-outs. But at what costs? At this current point in time when more and more documentation and accountability is expected of the medical profession, what would be acceptable and what not?

How do we draw the line on what is ethical and what may be professionally dubious or even reckless endangerment?

We must each and every one of us, contemplate and decide for ourselves, periodically and conscientiously that what we profess as medical therapy are indeed in the best interests of our patients—our raison d’être for our existence.

Our pecuniary, entrepreneurial or other self-enhancing interests must always be subservient to this singular precept, and we must make that especial effort to keep this alive and as an overarching conscience to contain our potential excesses.

How best can we help avoid or contain our moments of weakness, or madness? Simple, and yet perhaps the hardest to implement… review our code of professional conduct frequently, be mindful of our Medical Act at all times, and keep our medical professionalism at our highest level of conscientiousness always. Be what our medical training has always taught us to do—the right stuff!

Let us strive to forever be known as healers par excellence, and not be remembered for lesser baser misconduct or acts unbecoming. Let us always tame our recurrently straining moments of madness, and retain our moral anchor always.


[MMA Editorial, June 2006; Vol. 36 (6):pg7-8]

Medicine is not just a career, but a calling... by Dr. Lee Wei Ling

Medicine is not just a career, but a calling.

by Dr. Lee Wei Ling (Lee Kuan Yew's daughter)

 

I have always felt keenly the suffering of animals. Since I was a child, I had wanted to be a vet. My parents persuaded me to abandon that idea by using the example of a vet whose university education was funded by the Public Service Commission. When he returned to Singapore , he was posted to serve his bond at the abattoirs. That was enough to persuade me to select my second career choice – a doctor. I have never regretted that decision.

 

There are still many diseases for which medical science has no cure, and this is especially true of neurological diseases because nerve cells in the brain and spinal cord do not usually regenerate. Hence, a significant percentage of patients seeing neurologists, of which I am one, cannot be cured. But as in all areas of medicine, we still try our best for the patient, ‘to cure, sometimes; to relieve, often; to comfort, always’.

 

An example is a 70-year-old woman who sees me for her epilepsy. Her husband has taken a China mistress whom he has brought back to his marital home. He wants my patient to sell her 50 per cent ownership of their HDB flat and move out. Her children side with the husband because he is the one with the money and assets to will to them.

 

When this patient comes, I always greet her with a big smile and compliment her on her cheongsam. She will tell me she sewed it herself, and I will praise her for her skill. Then I ask her whether she has had any seizures since the last time she saw me. She sees me at yearly intervals, and usually, she will have had none.

 

Next, I ask her how she is coping at home. She would say she just ignores her husband and his mistress. I would give her a thumbs-up in reply, then ask her whether she still goes to watch Chinese operas. She would say yes.

 

By then, I would have prepared her prescription. I hand it to her, pat her on her back and she would walk out with a smile on her face, back straight and a spring in her step.

 

It takes me only five minutes to do the above. I can control but not cure her epilepsy. But I have cheered her up for the day.

 

One very special patient, Jac, has idiopathic severe generalised torsion dystonia. By the age of 11, she was as twisted as a pretzel and barely able to speak intelligibly. She did well in the Primary School Leaving Examination, but was a few points short of the score needed for an external student to be accepted by Methodist Girls’ School (MGS).

 

I had done fund-raising for MGS prior to this and knew the principal. I phoned her and explained Jac’s disease as well as her determination and diligence.

 

I told the principal that the nurturing environment of MGS would be good for Jac, and that it would be a good lesson for the other students in MGS to learn to interact with a peer with disability.

 

At the end of Secondary 2, Jac mailed me a book and a typed letter. The book was a collection of Chinese essays by students in MGS.

 

There were two essays by Jac. In addition, she had topped the entire Secondary 1 and, subsequently, Secondary 2 in Chinese. She was second in the entire Secondary 2 for Chemistry. She was happy at MGS, and her peers accepted her and helped wheel her around in her wheelchair.

 

Medication merely gave Jac some degree of pain relief from her dystonia. Being admitted to MGS gave her the opportunity to enjoy school and thrive in it.

 

I was walking on clouds for the next few hours after I received the book and letter. Jac showed that an indomitable human spirit can triumph over a severe physical disability. As a doctor, I am not just handling a medical problem but the entire patient, including her education and social life.

 

I have been practising medicine for 30 years now. Over this period, medical science has advanced tremendously, but the values held by the medical community seem to have changed for the worse.

 

Yearning and working for money is more widely and openly practised; and sometimes this is perceived as acceptable behaviour, though our moral instinct tells us otherwise.

 

Most normal humans have a moral instinct that can clearly distinguish between right and wrong. But we are more likely to excuse our own wrongdoing if there are others who are doing the same and getting away with it.

 

These doctors who profit unfairly from their patients know they are doing wrong. But if A, B and C are doing wrong – and X, Y and Z too – then I need not be ashamed of doing the same. Medical students who see this behaviour being tacitly condoned will tend to lower their own moral standards. Instead of putting patients’ welfare first, they will enrich themselves first.

 

The most important trait a doctor needs is empathy. If we can feel our patient’s pain and suffering, we would certainly do our best by our patients and their welfare would override everything else.

 

Medicine is not just a prestigious, profitable career – it is a calling. Being a doctor will guarantee almost anyone a decent standard of living. How much money we need for a decent standard of living varies from individual to individual.

 

My needs are simple and I live a spartan life. I choose to practise in the public sector because I want to serve all patients without needing to consider whether they can pay my fees.

 

I try not to judge others who demand an expensive lifestyle and treat patients mainly as a source of income. But when the greed is too overwhelming, I cannot help but point out that such behaviour is unethical.

 

The biggest challenge facing medicine in Singapore today is the struggle between two incentives that drive doctors in opposite directions: the humanitarian, ethical, compassionate drive to do the best by all patients versus the cold, calculating attitude that seeks to profit from as many patients as possible. Hopefully, the first will triumph.

 

Doctors do have families to support. Needing and wanting money is not wrong. But doctors must never allow greed to determine their actions.

 

I think if a fair system of pricing medical fees – such that doctors can earn what they deserve but not profit too much from patients – can be implemented, this problem will be much reduced. The Guideline of Fees, which previously was in effect, was dropped last year. I am trying to revive it as soon as possible.

 

The writer is director of the National Neuroscience Institute.

I was born and bred in Singapore .

This is my home, to which I am tied by family and friends.

Yet many Singaporeans find me eccentric, though most are too polite to verbalise it.

I only realised how eccentric I am when one friend pointed out  to me why I could not use my own yardstick to judge others..
 

I dislike intensely the elitist attitude of some in our upper socio-economic class.

 I have been accused of reverse snobbery because I tend to avoid the wealthy who flaunt  their wealth ostentatiously or do not help the less fortunate members of our society.

 

I treat all people I meet  as equals, be it a truck driver friend or a patient and  friend who belongs to the richest family in Singapore .

I appraise people not by their usefulness to me but by their character. I favour those with integrity, compassion and courage..

 I feel too many among us place inordinate emphasis on academic performance, job status, appearance and presentation.

 

 I am a doctor and director of the smallest  public sector hospital in Singapore , the National Neuroscience Institute (NNI).

 I have 300 staff, of whom 100 are doctors. I emphasise to my doctors that they must do  their best for every patient regardless of paying status.

 I also appraise my doctors on how well they care for our patients, not by how much money they bring in for NNI.

 

My doctors know I have friends who are likely to come in as subsidised patients. I warn them that if I find them not treating any subsidised patient well, their appraisal - and hence bonus and annual salary increments - would be negatively affected. My doctors know I will do as I say..

 

 I remind them that the purpose of our existence and the  measure of our success is how well we care for all our patients - and that this is the morally correct way to  behave and should be the reason why we are doctors.

In NNI, almost all patients are given the best possible treatment  regardless of their paying status.

 My preference for egalitarianism extends to how I interact with my staff. I am  director because the organisation needs a reporting structure...  But my staff are encouraged to speak out when they disagree with me.

This tends to be a rarity in several institutions in Singapore .

The fear that one's career  path may be negatively affected is what prevents many peoplefrom speaking out.

 

 This reflects poorly on leadership. In many organisations, superiors do not like to be contradicted by those who work under them. Intellectual arrogance is a deplorable attitude. 

'Listen to others, even the dull and ignorant; they too have their story,' the Desiderata tells us.

It is advice we should all heed - especially leaders, especially doctors.

 I speak out when I see something wrong that no one appears to be trying to correct.
 

 Not infrequently, I try to right the wrong. In doing so, I have stepped on the sensitive toes of quite a few members of  the establishment. As a result, I have been labelled 'anti-establishment'.

 

Less kind comments include:

 I am indifferent to these untrue criticisms; I report to my conscience; and I would not be able to face myself if I knew that there was a wrong that I could have righted but failed to do so. I have no protective godfather.

 

My father, Minister Mentor Lee Kuan Yew, would not interfere with any disciplinary measures that might be meted out to me.

 

 And I  am not anti-establishment. I am proud of what Singapore has achieved.

 But I am not a mouthpiece of the government.

 I am capable of independent thought and I can view problems or issues from a perspective that others may have overlooked.

A few months ago, I gave a talk on medical ethics to students  of our Graduate Medical School.

 They sent me a thank-you card with a message written by each student.

One wrote: 'You are a maverick, yet you are certainly not anti-establishment. You obey the moral law.'

 

 Another wrote: 'Thank you for sharing your perspective with us and being the voice that not many dare to take.'

It would be better for Singapore 's medical fraternity if the young can feel this way about all of us in positions of authority.

 After the SARs epidemic in 2003, the Government  began to transform Singapore into a vibrant city with arts and cultural festivals, and soon, integrated resorts and night F1.

But can we claim to be a civilised first world country if we do not treat all members of our society with  equal care and dignity?

There are other first world countries where the disparity between the different socio- economic classes is much more extreme and social snobbery is even worse than in Singapore .

But that is no excuse for Singaporeans not to try harder to treat each other with  dignity and care.

After all, both the Bible and Confucius tell us not to treat others in a way that we ourselves wouldnot want to be treated.

I wish Singapore could be an exception in this as it has been in many other areas where we have surprised others with our success.

Health Reform: Understanding the Social Dynamics of Health equity & costs, Government’s role, Public response and responsibility

Health Reform: Understanding the Social Dynamics of Health equity & costs, Government’s role, Public response and responsibility

Dr David KL Quek, drquek@gmail.com

“Those whose perspective is limited are likely to err in judgment, taking wrong turns, making bad judgments, and inflicting harm on others… Narrow-minded thinking undermines dynamism and prosperity… The ancient saying that goes, literally, ‘The thinking of a wise sage turns thrice a day,’ is meant to say that the sage is always receptive to new ways of thinking—that is, ready to learn new lessons and see by fresh perspectives. It behooves us to avoid rigid ways of thinking.” ~ Konosuke Matshushita (Founder of Panasonic)[1]

“In every country, regardless of its economic position, the future is likely to include severe pressure to increase value for money in health care. Governments will need to respond intelligently, or face public/voter acrimony, a loss of solidarity underpinning health care, and avoidable ill health, that in turn damages economic prospects. Given the great difficulty of examining the impact of different, often diffuse policies, the necessarily limited evidence base, and the length of time needed to develop policies and implement them, decisions as to the best approaches to reform may be necessarily based more on pragmatism, experience, instinct, and ideology than evidence. Pooling international experience here will be crucial and may help to short cut years of otherwise well-intended but ineffective reform.”

~ Jennifer Dixon and Vidhya Alakeson, Nuffield Trust[2]

Health—an indispensable social structure

Most people accept that health is a human right. Everyone expects that whenever anyone falls ill or suffers an injury, he or she is entitled to some form of treatment, especially first aid or resuscitation, even lifesaving surgery. The question of costs is usually not considered upfront, and is regarded distasteful if broached or worse, demanded!

It has become an accepted custom that society finds some mechanism to pay for such a system of entitlement. It would appear socially unacceptable even reprehensible, if a patient presents to any health facility and be turned away because of inability to pay for the service, worse if the injury or ailment appears life threatening!

However, despite this expectation, it has always been known that if one goes to a public sector health facility, some degree of waiting and queuing is in order. And unless this is grossly or unbearably prolonged, most patients would accept such a mechanism of service, given the constraints of reality—people sort of know that there is some need or basis for prioritizing, for triaging, for rationing; although sometimes this sequence of events may be broken and loudly complained about.

Historically however, healthcare has had a checkered and less salubrious past. Even as recently as the last 18^th-19^th century, most people could not afford ‘professional’ medical care. Medicine though long in history, was still at its infant magical if wondrous best, with more diagnostic physician prowess than actual lifesaving therapies or cures.

Clever prognostication or dubious amelioration of pain and suffering appeared to be the usual outcome of then medical encounters. Poor houses were aplenty where quasi-scientific medicine was practiced. The hapless ill and the poor were often tested upon for case studies or for much needed experience building for younger aspiring doctors/surgeons. Many ordinary people had even less rights than perhaps even a domestic pet or a draft horse.

More than anything else, public health measures such as sanitation and sewage reforms ultimately changed the dire consequences of the squalid ghettoes, tenements and working and living conditions for the indigent. Doctors then only performed house calls or carried out highly dubious surgeries, bloodletting, leaching, cupping, blistering, etc. for a fee, or for some barter exchange of goods or services. Wandering ‘surgeons’ and stone-cutting, cataract-extracting barbers were the lesser peripatetic tradesmen who thrived on providing some painful ‘cures’.

The poor really did not have any assured access to any doctor. At best they availed themselves only to traditional ‘snake-oil’ health restoratives and old wives’ tales of magical panaceas and ‘cure-alls’. Social conscience did not really pervade the 19^th century until enlightenment gradually resulted in wider egalitarian spread of ideas, humanising man as man and not man as indentured serfs or slaves!

However, over time most countries of the world have accepted the moral imperative that attaining the best possible standards of health is an inalienable moral and legal right.[3]

Health as a Human right

It was the ‘British laws’ in 1802 that led the way in establishing that ‘health’ was a civil right and expected public goods, triggered by the dreadful health conditions and threats among the destitute of the Industrial Revolution.

In 1925, Chile became the first enlightened nation ever to incorporate the right to health into its constitution. Surprisingly, despite its capitalistic bent, 72% of Americans strongly believe that health care should be considered a human right, in a poll undertaken in 2007. However, this is not enshrined in its constitution or laws.[4] Therefore, America remains ambiguous about labeling health as a human right. While the United States is a signatory to ICESCR (International Covenant on Economic, Social, and Cultural Rights), it has yet to ratify this key treaty, unlike the other 160 nations.

A recent paper exhorts for a more enlightened premise for American healthcare: “It is an assertion of the responsibility of governments to strive for ‘the highest attainable standard of physical and mental health.’ It is an asseveration that governments will respect, protect, and fulfill the right to health by ensuring the availability, accessibility, acceptability, and quality of the care required. It is an averment that governments will honor the tenets of accurate information, nondiscrimination and equality, and participation. It is an avouchment that governments will address the ‘underlying determinants of health’ such as sound housing, clean water, and adequate nutrition, especially as these determinants apply to the needs of poor and other marginalized populations.” [5]

These days more than 100 countries boast a commitment to the right to health or health care in their national constitutions.[6]

Thus aligning oneself with such social scruples as ‘health for all’ is a fairly modern societal phenomenon. We all believe that attaining health is a rightful and timely human development goal for everyone.

Sadly however, healthcare equity appears once again to be overshadowed and challenged by a rising consumerist-capitalist mindset. Many people increasingly deem self-preservation as their overriding personal philosophies of self-interest and self-advancement. There are mounting qualms of yielding too much perceived individual sacrifices, and diminution of individual space and choice, in deference for the avouched ‘greater good’ for more people or others…

Simply put, every man wants only to pay for those things or services, that he can afford for himself and perhaps for his immediate family: he is less willing, even unwilling to contribute to the benefit of others, unless forced upon him to do so by certain laws or authority, i.e. an overarching hegemon, a Leviathan.

Of course, many of our more socialist-minded colleagues might take exception to such a deconstruction of our healthcare dilemma or such a cold depiction of our self-interested persona. Perhaps in reality there might be more selfless religious practitioners, altruistic persons than they have been given credit for. Many do believe that healthcare is an irrevocable human right—that governments of all nations have a duty to provide adequate allocations to ensure such a nonnegotiable social prerogative!

My personal social perspective is generally altruistic, but also realistically sober. I have always enunciated such a stand, that man needs to be more humane, more human—this is ideally, politically correct. Pragmatically however, rising costs and competing demands have made such a commitment extremely difficult to follow-through, for many a people eking out a living! Hence, I also understand that more and more people are drifting toward a less charitable self-serving mindset… notwithstanding the fact that we continue to constantly remind ourselves, and others, of society’s inherent goodness—that we must be greater than our sum of individual identities and self-interests.

But I have been accused of being too preachy, too idealistic, too goody two shoes, which often rankle many who simply wish to be left alone to their own devices… Many would simply switch off, rather than to be bothered by conscience-disturbing ‘noises’ or moralizing sound bytes!

Health vs. Competing Public Goods & Services—Reality of Rationing Care

Our complex society however, ensures that we have even more convoluted contending requirements or partisan needs. The harsh reality is that healthcare is simply just one of the many competing public goods that most governments have to juggle with, particularly with finite yet gradually diminishing fiscal resources. Everyone is always trying to appease and accommodate disparate if expedient and politically-correct rival demands. There is no right or wrong in this, certainly no one model that encapsulates the best approach.

Thus, there will always be some degree of healthcare rationing or compromise.[7] Some have argued however, that governments which undercapitalized their health system tends to get away by under-servicing and under-provisioning, thereby justifying the very limited services available to their charges because of this low or under-allocation of funds.

Lack of supply side services would invariably lead to greater delays and queues. This in turn, directly or conveniently discourages public demand due to enforced wait times: for some, inability to wait leads to resorting to private care; or for others without means, stoically resigning to the fate of waiting in lines—the ultimate unvarnished truth of the powerless…

Fewer people are willing to pay for others who have not seen fit through their own personal efforts or capacities to help look after themselves, their families and their own socioeconomic interests. Everyone is expected to make reasonable contributions toward covering such eventualities. ‘Fend for yourselves’, everyone seems to imply. Certainly not everyone can.

Because, there would certainly be those who are genuinely destitute or disadvantaged—they cannot afford to contribute beyond their ‘poverty’ level. Disposable income is already very marginal among the poor in most countries. Health just does not figure high up in their hierarchy of immediate personal or family needs! Sadly, in many parts of the world including developed nations, this group of the poor and the marginalized is growing.

In the USA alone nearly 50 million people are uninsured.[8] They are thus exposed to the extreme whims and the flawed quality of erratic health care, mostly via emergency department visits with no long-term follow-through solutions to their more chronic ailments! Thus, health outcomes remain substandard and below that achievable by those who have insurance or means.

For the poor, most people expect the government to take care of this, in as unobtrusive a manner as possible, preferably without jarring our own comfort zones and our conscience. We expect the government to provide these social safety nets, at bare minimum encroachment on others, certainly not to reduce the expected benefits for ourselves. Certainly this is the overriding version of the American psyche, which threatens to miscarry the Obamacare health reform—notwithstanding the sporadic clanging discordant sound bites from the “Michael Moore”s of alternate views.

Many Americans and I dare say even Malaysians, are simply not prepared to spend any more to help others, merely because the latter cannot afford to do so for themselves. Modern society is more self-centred and less altruistic. Paradoxically however, the latter characteristic is demanded of medical professionals, and perhaps also of the governing authorities, which should somehow provide the necessary facilities and source the appropriate funds!

The difficulty in offering any modicum of healthcare service is that this is an ill-defined bottomless pit. What and how much healthcare can be provided as universal coverage for all? What constitute indisputably as necessary services? How do we determine unavoidable variations of coverage? What about less evidence-based, more questionable or very marginal benefits of some care options? How does one define what constitutes emergency care or barest basics medical care, fully accessible to everyone? Or should every conceivable healthcare service be made freely available to just everyone?

The complexity is trying to agree on the minimum basket of healthcare services that everyone is entitled to, without undue strains as to costs. We expect this would be provided as an inclusive basket of rights, through prudent payroll or government tax revenue allocations, and hopefully not through another reimbursement mechanism or another additional levy, social health insurance, whatever, etc. Remember, most Malaysians are already against any idea of a GST type of taxation, which penalizes the poor more than the rich…

Where can we keep a lid on expectations to whatever comprehensive medical care possible? If someone has say, a cancer—how does one define how far to go with investigations, surgery, treatment and even access to experimental if marginally beneficial drugs, which cost astronomical sums? How much is a human life worth to keep sustaining or prolonging—a few years, a few weeks, or days?

What about a debilitating stroke or heart disease? Who should provide for some or all of the possible therapeutic modalities? Already many people baulk at having to take a polypharmacy of medications to reduce risk factors and improve function and survival. Does age or mental capacity or terminally-ill status, factor into this equation to provide or deny some of these quasi-beneficial treatments?

Costs can run into a significant portion of anyone’s wages, so who should subsidize, or should this be provided as a privilege, without copayment, etc? This is indeed the crux of why a collective social health insurance is so useful and a fairer mode of community-distributed risk sharing, why we should urge everyone to buy-in. Major catastrophic illness can and has bankrupted many people before and would do so again in the future, unless hedged by some form of community risk sharing.

Yet the converse is also alarming: the uninsured have poorer control of their diabetes, high blood cholesterol levels or achieving blood pressure goals. Not surprisingly, many uninsured in America are also those who have badly managed risk factors and therefore more inclined to suffer more complications and suffer poorer health outcomes![9]

Catastrophic illness and end of life care is frightfully expensive and accounts for as much as 60 to 95% of all lifetime healthcare costs![10] Would this economic consideration be different or the same for say a young person vs. an elderly dying? Whose life is worth more and who less? Can we play God? Should we? Would such huge costs be better applied for more life promoting health care for many more people? Would the rights of the many subsume to or override that of one special case?

Socioeconomic Realities & Essential Government Role

When it comes to health care, economic and social realities dictate that some form of rationing always have to be put up with. There is usually some agreed upon basket of health and medical services, which would form the bare minimum basis of access for all. It is rare that every possible test, medication or care is readily or fully accessible to everyone, on demand, or even when in need.

No health system in the world can provide every possible healthcare service on demand to everyone, without some constraints or queues. But for those who are able or willing, private purchase of such services is often expedited without delays and upon demand. This approach is impossible without free market mechanisms to private care access, but this is way too expensive for just about every person!

No system can survive without government intervention and contribution of government tax revenue allocations. But even this is proving to be too much for most modern budgetary prudence. Demand nearly always outstrips supply. There is always that moral hazard of everyone who is ill to demand and to expect to be tested and treated—early, quickly and comprehensively—often over-utilising scarce or limited facilities and costly resources.

Thus, there is growing need for citizen education, input, contribution and empowerment too—there needs to be buying in by citizens. More and more health authorities now recognize that some form of co-payment or premium payments toward some form of social health insurance, is needed. This is crucial so that everyone then has a responsibility in knowing that because they are contributing to this finite fund, they have a joint duty to use this fund prudently and responsibly, and with collective social conscience.

It is important that every citizen recognize that health is an essential social service which although usually provided for or ‘guaranteed’ by government, is not a given.

Many lesser-endowed countries usually do not apply sufficient attention or resources to this sector, which is why poorer economies have citizens who have poorer sanitation, more communicable diseases, have shorter life expectancies. They generally lack access to even basic healthcare services, suffer high maternal and child mortalities, and most need to pay extraordinary out-of-pocket expenses to buy even a small modicum of medical services.

But enlightened governments usually allocate sufficient resources to health as a critical social service, which is provided through tax revenues or specially apportioned allocations or levies. However, there must be true accountability and transparency as to the use of such funds so that people can feel satisfied that there is as little wastage and leakage from administrative or improper practices. Otherwise, this will prove to be very unpopular and many among the citizens would resist such an extra form of GST-like taxation.

If everyone understands this social need for such a contribution, then it would be easier to discuss the harder options more sanguinely. It is critical to explain that there is no such thing as a ‘free lunch’ in healthcare, because demand for health services will almost always exceed any country’s finite resources.

But unfortunately for many Malaysians, there have been confusing stands made by the authorities: on the one hand pledging free healthcare for the needy, while on the other, also asking the rest of the public to pay more. The government appears to be flip-flopping, making reassuring sporadic pronouncements of free or almost free healthcare services, especially during political posturing, while also warning about subsidy removals, when in more sober moments of tackling budget deficits!

Greater Government allocation for Healthcare Critical

Of course, this is not to deny the fact that our very poor citizens need to be protected—that we need a more robust structure of social safety nets. But apparently we do have a large segment of our population whose family income is less than RM2000 per month, which would place them in the “poverty” level, even if not defined as hard core poor. There is an estimated 40% of the working population under this category! This is indeed a huge burden!

Because of this, most civil society advocates have urged our government for larger allocations for healthcare, up from the current 2.1% to at least 4 to 5% of the GDP. This might help boost private enterprise contribution by a similar margin, whose current contribution amounts to only 2.7% of the GDP.[11]^,[12] So do we have the political will to do this well and fairly? Instead of the usually paltry RM12 to 13 billion a year, an allocation of some RM25 to 30 billion would certainly help boost the coffers for much needed restructuring efforts, catering to the poorest and the needy.

Importantly, how do we allocate these much-needed funds more openly, more prudently, so that citizen misgivings and resistance can be allayed? This will be the true test of the government’s sincerity and commitment to good governance in the delivery of such dutiful intrinsic public goods and services!

We have to move away from entitling concessionaires or special interest groups or companies to handle some of these critical services. Special negotiated contracts should be done away with; they reek of too much cronyism and rent-seeking patronage, which not only have become despised buzzwords, but also increase costs without the attendant benefits of cost-effectiveness. This results in unnecessary leakages and decreased productivity.

Transparent and prudent allocation of funds would encourage our citizens to accept greater contribution towards some collective sharing of healthcare costs and community-rated insurance, when they know their money and tax contribution is well spent.

The MMA urges the government to set up a more structured healthcare social safety net system, which must include such crucial need-based Medicaid, Medicare and CHIP (for children). This social construct already available in many developed nations, would be that crown in the accepted array of government sponsored public goods, funded from tax allocations. Such subsidised care would exempt these poorer or retired (noneconomic-wage earning) groups from contributing to the planned SHI. With this in place, we can then calculate more accurately how much each paying citizen can contribute, as painlessly as possible!

The most important part of any health reform is the appropriate and frugal utilization of this finite health fund, the actual structure of the services, which should not marginalize or sideline any stakeholder. Most importantly our public and our patients should not suffer the worse for it due to disruptions caused by inept, technical or corrupt glitches!

Dialogue & Consultation with Civil Society Vital

Medical doctors should be at the forefront of such changes and must be allowed the greatest feedback and consultation, as they are the ones on the ground running. They have enough clinical experiences, albeit not the technical knowledge about macroeconomic costs and personnel requirements, etc. of how to exactly do what is right or practical.

It is true that doctors would have their vested interests, but collectively doctors have always been greater than their individual selves. Most medical groups would always tend toward the greater public good, while subsuming their own self-interests.

However, most doctors just do not have the expertise, energy or time to study these restructuring plans in detail or minutiae. Sadly, we do not even have any comprehensive documents to review or study, for helping to streamline or improve some of these plans and programmes. This contrasts starkly with the nearly 100 odd publications and technical details made available on the new ‘Liberalising the NHS’ reforms, first mooted last year! [13]^,[14]

But as interested professionals with responsibilities, the MMA must rise to the occasion and immerse itself into this process, and our members must be more ready to participate in this ongoing dialogue. Otherwise, we would truly be marginalized and left on the wayside!

Sadly too there has been a desperate dearth of research and publications (whether for discourse or debate) on many of these absolutely necessary health policy issues. Our Universities must do more to encourage more academic as well as research-based practical, economic and policy health studies, so that we can have clearer definable information about ‘real’ data from the ground, which can help create better systems.

Physicians must take the lead; we cannot afford to be apathetic and adopt a ‘couldn’t care less’ attitude! Neither would it do, to simply complain on the sidelines—we must get involved and participate by coming forwards to be engaged in the process and in helping to steer the direction of healthcare transformation. Griping and hoping that interested physicians out there and ‘others’ would do the job for them, is just what is wrong with the process these days. More must come forward to actively take part, and play a more critical helpful role.

Medical professionals must take part in understanding and studying these consequences of changing health care across the globe, and particularly in this country. We just have to! No one else would understand the healthcare scenario better, if we allow the powers that be a free rein at structural reforms, which could impact the profession, our patients and the public, radically and irreversibly!

But recognizing these physician-led social duties and responsibilities is not new. In the 1930s just after the Great Depression, the Committee on the Costs of Medical Care, chaired by Stanford University president, Dr. Ray Lyman Wilbur, recommended that “Medical service should be more largely furnished by groups of physicians and related practitioners, so organized as to maintain high standards of care and to retain the personal relations between patients and physicians.”[15]

So, it is this constantly shifting dynamic of balancing demand with need and supply at the best cost-efficiency that most nations try to achieve a modicum of equilibrium. Otherwise, these nations face runaway healthcare costs and fractured disruption or meltdown of their health services!

The leadership of the American College of Cardiology recently urged physicians and public policy makers to work together when enacting any major changes in health care reform, especially when it comes to point-of-care professionalism where standards and quality of patient care must not be compromised, in the continued search to contain healthcare costs:

   “The right amount of care and how best to deliver it is uncertain. Medical care is a point-of-care interaction between the patient and a clinician. It is a blend of the observations, fears, and concerns of the patient balanced by the expertise and experience of the clinician. This joint decision-making is a balance of the art and science of medicine. At its best, it is exceptional. At its worst, it can include inappropriate care because of knowledge-based deficiencies or even personal financial gain. In truth, it is easier to identify blatant overuse than errors of omission… The goal for the best health care, however, is not harmonization of a utilization map but deciding the right amount of care at the right time.”[16]

But more than 20 years on, the dynamics have changed tremendously—we have seen the establishment of even more private hospitals and clinics, which have grown to absorb some 62% of the outpatient clinic consultations of the Malaysian public, some 65 million patient visits out of more than 100 million such outpatient encounters. But because of higher cost considerations, hospital use in the private sector only cater to some 30% of the population, with 70% still overcrowding the heavily subsidized (less than 2% of the hospital cost is reimbursed by the patients) public hospitals.[17]

Hence, there is widening discrepancy in access and use of these health services, which lead to greater delay and longer queues for those who cannot afford the private sector. The public hospital sector with its constantly short staffing problems continues to look after the rest of the 75% who need hospitalization for more difficult surgeries and therapies.

Can we now suddenly merge and integrate these two systems, private and public seamlessly, without adequate comprehensive planning and exchanges of ideas and details, about how best to bring this about without upsetting the current system and endangering this working if imperfect system?

Mustn’t we be more involved in this national dialogue to truly improve the system together, and not in fits and stutters, and certainly not in possibly disruptive experimentations…?

---

[1]Konosuke Matshushita, The Path, McGraw-Hill, New York, 1968.

[2] Jennifer Dixon, Vidhya Alakeson. Reforming health care: why we need to learn from international experience. The Nuffield Trust Briefing, September 2010.

[3] United Nations, Economic and Social Council. Substantive Issues Arising in the Implementation of the International Covenant on Economic, Social and Cultural Rights (ICESCR): General Comment No. 14: The Right to the Highest Attainable Standard of Health. http://www.unhchr.ch/tbs/doc.nsf/%28symbol%29/E.C.12.2000.4.En. Accessed November 22, 2010.

[4] The Opportunity Agenda. Human rights in the US: opinion research with advocates, journalists, and the general public. August 2007 http://opportunityagenda.org/files/field_file/Human%20Rights%20Report%20-%202007%20public%20opinion.pdf. Accessed November 22, 2010.

[5] Eric A. Friedman, Eli Y. Adashi. The Right to Health as the Unheralded Narrative of Health Care Reform. JAMA, December 15, 2010: 304(23): 2639-2640.

[6] Kinney ED, Clark BA. Provisions for health and health care in the constitutions of the countries of the world. Cornell Int Law J. 2004;37:285-355.

[7] Donald W Light, The real ethics of rationing. BMJ 1997;315:112-115 (12 July)

[8] Matthew Buettgens, Bowen Garrett, and John Holahan. Why the Individual Mandate Matters. Timely Analysis of Immediate Health Policy Issues. December 2010. Urban Institute. Robert Wood Johnson Foundation. http://www.rwjf.org/files/research/71601.pdf (Accessed 3 Feb 2011); pg 3.

[9] Schober SE, Makuc DM, Zhang C, Kennedy-Stephenson J, Burt V. Health insurance affects diagnosis and control of hypercholesterolemia and hypertension among adults aged 20–64: United States, 2005–2008. NCHS Data Brief, no 57. Hyattsville, MD: National Center for Health Statistics. 2011.

[10] Mike Mitka. Hospitalizations for Extreme Conditions Mean Extreme Expenses, Study Verifies. JAMA, December 15, 2010—304(23): 2579-2580

[11] David KL Quek. Budget 2010: What’s in it for Health Care?

[12] Ministry of Finance, Government of Malaysia. National Budget 2010

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