A lady was explaining to a man how a “kick-back” deal works and in her enthusiasm to explain with an example she made a case in point of doctors sending patients for blood work-ups to pathology labs and receiving an assured kick-back in return. It was partly the words that caught my attention, and partly how they were spoken: casually, carelessly, plainly. A distasteful fact, spoken easily without aversion or disgust, in fact with a hint of approval and used to validate some other deal she was trying to make.
In fact it was obvious that to her getting a monetary “kick-back” for a professional reference was a mundane fact, one that she accepted wholeheartedly, and did not deliberate over. Contrary to this view there are many who would find the concept of accepting a “Kick-back” improper and offensive; morally corrupt.
This overheard conversation got me thinking about two issues:
- What is “right” and what is “wrong”; “moral” and “immoral”; and whether morality can be objective.
- Prejudging or generalising issues when they are associated with professions such as medicine, which demand “Quality” over “Quantity”; and the effect such judgements can have on services available to the patient.
Morality, according to me is a set of personal values of an individual, or a code of conduct decided up on by an organisation or firm. It need not/ cannot be standardised to apply to a whole society, must not be policed or enforced, and need not be uniform in structure or content. However, one’s personal or organizational ethical boundaries cannot tread over the legal, social or ethical rights of another. In an industry/ profession where “service” or “opinion” is offered and dispensed, the morality of one is closely associated with the fundamental rights of another. In the Medical Profession if decision making, advising, or referring is directed by the smallest hint of financial or other gains for the consultant, the patient’s rights have immediately been violated.
But are medical professionals accepting “kick-backs” the only ones that violate a patient’s rights? Are all medical professionals who accept such remuneration equally guilty? Can anyone “Quantitatively” measure whether the “Quality” of advice given was most favourable/ most beneficial to the patient in those particular circumstances?
Here the medical profession becomes unique in its functioning, because two variables are interacting with each other and the probabilities in terms of outcomes become infinite. The education, knowledge, usable experience, comprehension of the problem at hand, and morality of the Doctor interacts with the condition, perception, expectations and psycho-social make up of the patient.
Healing a patient requires a many pronged approach; experienced and perceptive Doctors reach beyond their skills and sometimes use their sensitivity to diagnose and advise. I remember, a long while ago when I was just out of Medical school I had laughed at a simple rural patient, who while giving me her history, had very seriously told me that she was cured of stomach pain after the Doctor treating her did an “X-Ray”. Many years later, I now know that sometimes investigations that the patient can read, hold, and see, can and do work in healing, or in convincing the patient to follow medical advice. Simply put, investigations not only help the doctor to diagnose, they also give the patient tangible proof of illness or good health. Depending on the Doctor’s diagnostic skills (which are hard to define or measure) and perception, investigations that he/ she may ask for may differ. Furthermore, certain investigations like MRI or diagnostic USG may require human skills (specialised radiologists) to interpret results and modify ongoing scans. As interpretation and reporting is again “qualitative” or enhanced by experience, clinicians may have preferred choices of where to refer their patients for some investigations. Not all medical professional referring you for investigations and specifying where to go are accepting remuneration for reference.
Symptom and disease relationship is so diverse in the population that medical professionals/ consultants have to draw on vast knowledge, acquired wisdom and scientific application to diagnose, predict course of illness, cure and prevent disease processes. Delayed referrals, hasty procedures, ill-advised treatment choices and inadequate counselling for financial gains, or simply because of an indifferent attitude can all be labelled unfair and corrupt. In the medical profession, the sincerity and personal morals of the consultant can obstruct the right of the patient to obtain the best and most beneficial advice in the given circumstances. It is not possible to quantify the quality of medical advice that you received, and hence impossible to prove or refute inherent corruption.
A profession is a vocation founded upon specialized educational training, the purpose of which is to supply disinterested counsel and service to others, for a direct and definite compensation, wholly apart from expectation of other business gain (Quoted). Professions rise in status and power, they also sometimes decline and lose shine. In the medical profession, an unspoken hierarchy exists between Surgeons, Physicians, General Practitioners and allied professions. With the declining importance of some professions, unfortunately, the well educated doctor may also lose the ability to earn respectably. Sometimes giving or accepting a “Kick-back” may have nothing to do with compromised ethics, and may need a deeper social rethinking and aligning of work-compensation structure. The fact that your doctor gave or received a kick-back will not always compromise the quality of healthcare you receive and may not increase the cost of your treatment.
When we define the word “Profession” (as stated above) there seem to be four important parts to the definition:
- Specialized educational training: I would like to say that academic education and wisdom gleaned from constructive experience, combined with an ability to use sensitivity and scientific deduction to arrive at a diagnosis should all be considered in this segment. A doctor not qualified in any one or more of these aspects should not offer an unsupervised opinion to a patient seeking his counsel.
- Disinterested counsel to others: The ability to look at your patient as a “whole” person, to advise them on the basis of his/ her long term health and well-being, without considering your own speciality, interest and promotion. In short, while looking at the patient, the Doctor should have only the best overall interest of the patient in mind.
- Direct and Definite compensation: Though it may seem in the patient’s best interest to have some externally fixed fee structure for different medical specialities, it may not actually be so. Within reasonable limits, the professional should be allowed to choose the compensation he/ she needs for their counsel, as this will minimise the chances of corrupt practice. The fees, especially for procedures advised should be fully and clearly stated, and the patient should be well-informed. The Doctor should be completely satisfied with the compensation received and the patient should be willing to pay the same.
- No expectation of other business gain: Talking about compensation for referrals is the tip of the iceberg, and “Business gain” for doctors can come from various sources, like pharmaceutical companies, manufacturers of surgical instruments and implants, equipment manufacturers, etc. The Doctor should, of course only use commodities that will give the patient best results, and not use unnecessary procedures that do not ensure the patient’s long term well being.
This essay is not a comment on the morals of doctors who give or receive financial remuneration for referrals. Rather, it is an attempt to shed light on the complexity of the issue. It is important to remember here that the services offered have to be evaluated qualitatively, and the complexity of the matter is reflected here. The rights of the patient are supremely important, and a doctor who respects these rights and does not infringe on them for any kind of personal benefit is morally blameless.