Resolution: Medicine as a Patient Welfare Centered Professional Enterprise

No one can deny, or dispute, that the only justified reason the whole enterprise of medicine and its appendages can exist is patient welfare. Remove this one criterion and the whole system has to collapse. This applies as much to doctors as their ancillaries, including all the commercial establishments it has helped spawn. This ideal of patient welfare has been manipulated, sidelined, exploited, whatever. But no one can deny that this one criterion cannot be sidestepped. If any process seeks to deny this and yet exist, it cannot claim to do so on legitimate grounds.

Patient welfare is necessary, but not a sufficient enough criterion. For, to bring it about one needed the infrastructure and paraphernalia to ensure it. That requires funds. And running the enterprise of medicine as an efficient business could best generate it. Whoever decided to sanction anything and everything in the name of profit? Who has decided that business and profits necessarily involve malpractice? Why could ethics not play a role in business? For to brand every business as necessarily unethical, and therefore suspect, we apply a warped yard stick, and automatically sanction every wrong doing in the name of business. For we must believe that sound business also involves an abiding commitment to values. As one of the most successful of businessmen in India today mentions:

While success is important, it can become enduring only if it is based on a strong foundation of values. Define what you stand for as early as possible, and do not compromise with it for any reason. You can’t enjoy the fruits of success if you have to argue with your own conscience (Premji, 2004).

In other words, ethical guidelines are possible in business as well. In fact the whole field of business ethics seeks to forward precisely this. It is difficult, is prone to manipulation. And the majority, which cares two hoots at

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times, knocks it about. But it is implemental if we do not mentally sanction ulteriority as integral to business.

The whole point is how do we ensure that in profit making patient welfare is not compromised, and in patient welfare, profit making is ensured?

Let us take the example of a chemical reaction to clarify matters. Reactants on the LHS, Products on the RHS.

If the patients, clinician/researcher, along with infrastructure (including hospitals, pharmaceuticals, the distribution and training system involved, previous knowledge) become the reactants, the products are patient welfare, profits and advanced knowledge.

Patients +                                             Patient Welfare +

Clinicians/Researchers +                                Profits +

Infrastructure                                            Knowledge

(Reactants)                                              (Products)

Now, for ensuring the products that result are a wholesome mix, we must ensure on the LHS:

1. Patients are correctly identified, diagnosed according to evidence-based criteria, and handled with care, compassion and competence.

2. Clinicians/ researchers credentials are of impeccable standards, itself not a mean task;

3. Infrastructure updates itself periodically, and is tuned to react positively with the clinician/researcher. Again, something requiring quite an effort, especially the second part.

42 Ajai R. Singh and Shakuntala A. Singh

Processes that ensure quality control of these two reactants have to be firmly in place. For that, all those involved in formulating, regulating, modifying and evaluating procedures and processes to ensure quality check, control of reactants, and absence of pollutants have to be an ever-vigilant lot. And their procedures and processes have to be constantly updated. Like your Windows, or the anti-virus installed in your computer.

That is one side of the story.

Equally important is it to ensure a healthy mix of the products (RHS). Of course ensuring quality control of reactants is one major step. And here weeding out unhealthy practices as well as encouraging wholesome ones is a must. But equally important is it to determine what is a healthy mix. What proportion of products ensure that the reaction had been successful? The products are optimal? And the gangue is minimal? And the corpus of knowledge that results is wholesome and patient welfare oriented?

We think a healthy proportion is patient welfare with profits, in that order. Such amount of patient welfare as also ensures profit, and such amount of profit as also ensures patient welfare. Because:

Profit, without patient welfare,is blind. Patient welfare, without profit, is lame.

That proportion of patient welfare which ensures profit is necessary. And that proportion of profits which never neglects patient welfare is as necessary. For to try to ensure patient welfare without profits is a lame exercise, and would always fail. Just as to ensure profits without patient welfare is a blind enterprise, and would always falter. So, if we do not wish to fail, or falter, the only resolution is that proportion of patient welfare which also ensures profits, and that proportion of profits which also ensures patient welfare. Any compromise in this formulation and we know what it means.

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Let us put it a little differently to clarify the issue further. Patient welfare, essentially, is lame. Lame meaning it cannot go far on its own. It needs to ride on something. Similarly, profit, essentially, is blind. It too cannot go ahead on its own because it lacks vision. It needs to be directed by something.

If patient welfare becomes the eyes, and profit becomes the legs, then they could complement each other. Lame patient welfare could ride on, and direct, blind profit, and both could reach their destination. In this both parties must know that none is superior to the other, both suffer from a disability, and both need the other to survive. It is as foolhardy for patient welfare to believe it can do without profit, as it is mischievous for profit to believe it can do without patient welfare. The recent spate of lawsuits should have made this amply clear to it.

Hence a lame patient welfare could climb the back of a blind profit, and both could complete the journey.

However, if the blind decided to chart the course and determine the destination, it would spell disaster. This was, in essence, what dishonest means of profit making by industry meant. And we know the fallout. Such means must be firmly resisted. Similarly, and equally important, if lame profit welfare want to complete the journey on its own, it would take a great amount of time. Besides, it may falter and fall, being unable to complete the journey on its own. This too has to be resisted. We know how without sufficient funds neither proper infrastructure nor further research can be forwarded.

Similarly, a blind patient welfare and a lame profit would also spell chaos. Blind patient welfare manifested as fanatical proponents of patient welfare who could see no merit in profits. Such thinking is naïve and would receive only lip sympathy, if at all. Similarly, lame profit, which could not provide the funds for scientific research would be equally disastrous, and could be the result of a blind patient welfare.

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It must be essentially lame patient welfare complemented by essentially blind profit. They have to coexist without switching roles, or usurping each other’s domain. There is no option for both of them if they wish to survive in the long run, and resolve their conflicts amicably.

This would automatically ensure that the other product, knowledge, also remained gangue free. For vitiated patient welfare and vitiated profits also ensure a vitiated knowledge corpus.

Let us go back to the chemical reaction formulation. Continuing from where we ended earlier:

If the patients, clinician/researcher, along with infrastructure (including hospitals, pharmaceuticals, the distribution, training system involved, and previous knowledge) become the reactants, the products were patient welfare and profits and new knowledge. What was worth noting was that it was a two way correspondence:

Patients +                               ( Two                 Patient Welfare +

Clinicians/Researchers +              way                    Profits +

Infrastructure                 Correspondence )            Knowledge                 

(Reactants)                                                   (Products)

 

Research/clinical care combined with infrastructure working on patients lead to patient welfare with profits and advanced knowledge. Patient welfare with profits, combined with advanced knowledge, in its turn, lead to further development in research/clinical care with infrastructure and work on patients. This is the cycle that perpetuates itself to the benefit of all concerned:

 

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                                          Patients +

                               Clinicians/ Researchers +

                                    Infrastructure

                                     (Reactants)

 

                                 Patient Welfare +

                                    Profits +

                                   Knowledge

                                  (Products)

 

Moreover, we have to note that there has to be a catalyst in this process. One that speeds and regulates the reaction but does not itself take part or undergo any modification. This necessarily has to be ethical conduct by all parties concerned. The final revised reaction has to be as follows:

 

Patients +                                                        Patient Welfare +

Clinicians/Researchers +      Two way                       Profits +

Infrastructure                Correspondence                   Knowledge

(Reactants)                   (Ethical conduct)                 (Products)

                            

 

Summing Up: Medicine as a Patient Welfare Centered Professional Enterprise

 

In short, we think of patient welfare as the center around which everything revolves, and forsaking which nothing does. And we continue to believe medicine is a profession. Meaning thereby, it is bound by the rules of professional ethics, requiring certain essential

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qualifications as enshrined in regulations by certain statutory authorities. But it is also, though not equally, an enterprise wherein the profits that accrue from its practice can be considered legitimate if it does not forsake patient welfare at any stage of its planning and action.

It is important that the profession of medicine should accept and allow for private enterprise in the field if it does not want nefarious activities to prosper clandestinely. Something like what it did for abortion. Not allowing it caused so much illegal trafficking, allowing it with safeguards took the sting out of malevolence. Something similar would happen if we accept the enterprise of medicine as legitimate, but with the necessary condition of patient welfare not to be violated at any time.

Hence medicine becomes a patient welfare centered professional enterprise.

We think it appropriate to leave you here with this thought for your serious consideration.

Decide which side to be on

In this year, 2005, we have seen natural disasters like earthquakes, tsunamis and hurricanes vie with man made disasters like terrorist attacks devastate human life.

A hurricane of ominous proportions is building up in the background in the form of lawsuits against industry. And it will join with the tsunamis of consumer court cases against the man with the stethoscope, and working under the microscope. And the earthquake that follows will shake the very foundations of biomedical advance, medical care and patient welfare as we have always known and upheld as proper.

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Disaster strikes. Be prepared. Decide which side you wish to be on.

Or be ready for the history of the Yadavas and the Romans to get repeated.

(Contd.)