Ethics thrown to the wind

In April 2010, Dr. Ketan Desai, the President of the Medical Council of India, ex-President of the Indian Medical Association and the President-elect of the World Medical Association (a kind of federation of medical associations of countries in the world), was arrested by the Central Bureau of Investigation (CBI), on charges of corruption. This was not the first time he was arrested for such charges. A decade back, as President of the Medical Council he had faced similar corruption charges, and in 2001, he was removed from the post of president following a judgment of Delhi High Court. But he clawed back to that position after getting out of the court cases.
Since the time when our country opted for privatisation and market de-controls as the dominant approach for development, there has been frequent reporting of corruption – each new case being the worse than the previous ones. Politics, business, sports, education, development programmes – there is no field not affected by corruption. So much so that many people tell me that it is no longer “juicy” to read or watch about the corruption – it is so normal. So the corruption in the field of medical care and among the medical professionals may not shock many. But, corruption is not a mere media story, it is also life and death issue for the patient. Objectively, it is a phenomenon of the way system is organised and governed. Therefore, in order to find a solution, it is imperative to understand its depth and mechanism.

A tip of the Iceberg
Dr. Ketan Desai’s case is interesting in the sense that for last 15 years, everybody knew about what he was doing, and yet most in the medical profession not only allowed him to do that but also kept electing him to the highest positions. It is easy to condemn medical councils as they are supposed to be “government bodies”, but he also easily climbed to the top of the non-governmental IMA and then internationally, the WMA. In fact this is the most fascinating, and hence the most deplorable feature of the corruption – that is often not secret, but carried out in public, everybody knows but all accept it as normal and when somebody is caught, all deplore the person while the corruption goes on.
Let us look at, among many, two other very important reasons why the medical profession is so tolerant to corruption. Nearly 90% of all doctors (we have over 1.3 million doctors of all systems of medicine) are in the private sector and/or even when being in public sector, do private practice. Three fourth of health expenditure is neither covered by the government nor by any insurance, but paid for by the people/patients from their own pockets directly at the time they seek care. This is something worse than even the market-loving USA where nearly half of the health expenditure is paid for by the government and the need for the out-of-pocket spending at the time of illness is kept very low. Our system thus force people to sell their assets during catastrophic illnesses, and contributes in creation of more poverty and the poor.
The contrast with the US does not end here. The market-based private health care in the USA is the most regulated system in world, while ours is the least regulated system. And that has encouraged massive corruption within the system. The “cut-practice” among doctors, hospitals and diagnostic centres is rampant, so much so that, it is normalized. In this system, a doctor referring patient to another doctor, to laboratory, to hospital, etc, etc get a commission from the person or institution. That means, the payment made by the patient to each actor and institution in process of his or her treatment is shared with one another. This is like the system of bribe being shared in the police department from the constable to the top – the only difference being that it is organised somewhat differently, and it is in the private sector. Is it then surprising that the one who was the most skilled at taking cut could climb the top position in the medical council and medical association?
Let us look at the second reason within the system of medical education. Till mid-1980s, India had around 125 medical colleges, of them over 100 were in the public sector. Yes, there was some favouritism and corruption, but nothing that ever hit the ceiling as it did after the government allowed all kind of private medical colleges. Now we have three times more medical colleges, over two-third in private sector, and run openly as commercial shops. They charge high capitation and annual fees, and provide real “reservation” to the moneyed class of the country. For others not having enough cash, there is excellent facility to take loan from banks to finance medical education. The doctors produced by this system, even those who are from the lower middle classes, have no other choice but to join the trading system on becoming doctors to pay back the massive bank loans that paid their fees.
The allegation against Dr. Ketan Desai is that he took bribe of crores of rupees from some private medical colleges. Why did these colleges give him bribe? Well, many of these colleges are more interested in making money than investing in the high standards of teaching and skill building of students. They needed recognition or accreditation of their colleges without meeting such high standards from the medical council of which Dr. Desai was president.

Market and malpractice
Clearly, the medical education and the medical practice are closely integrated in one system where the market and profit are driving forces. It is a system that puts premium on profit, while the quality and standards are expendable. That is why Dr. Desai is behind bars for last six months while those private medical colleges that are able to run their shops without adequate standards are flourishing. Dr. Desai’s imprisonment and the replacement of Medical Council by “seven wise-men” would seem to be only eyewash if they could not close down those substandard medical schools, and control the cost of medical education such that even the poorest of this country has opportunity to become a doctor.
About 12 years back I was in a late evening meeting in a tribal hamlet in north Gujarat. As a part of my research work I asked the assembled villagers their opinion of doctors. A villager spontaneously reacted, “Saab, are you asking us about daktars or dakoos (dacoits)”. Being a doctor, I was really taken aback. I am reminded of that episode whenever I hear complaints of patients about over-charging, too many diagnostic tests, and so on. In the market of health care the charging fees or price has merged so much with the “cut-practice” and bribes that the corruption is fast replacing all business practices. No wonder then that more people are damning the demi-gods of yester-years.

The writer is one of the founders of the Forum for Medical Ethics Society and its journal, IJME (Indian Journal of Medical Ethics, www.ijme.in) and is presently on its editorial board. He was National Coordinator of the two (2005 and 2007) National Bioethics Conferences of the IJME. He is also Managing Trustee of CEHAT (www.cejat.org) and CSER (www.cser.in) in Mumbai and SATHI (www.sathicehat.org) in Pune.

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