Paradigm shift in medical ethics
Dr KK Aggarwal
There has been a paradigm shift in the thinking of the public. There has been a corresponding paradigm shift in the dynamics of doctor-patient relationship; from paternalism to patient-centric. Today, patients want to be equal partners in decisions about their treatment with the doctor acting as a guide and facilitate decision making. Patient autonomy is also now at the forefront of the principles of medical ethics, along with non-maleficence (do no harm) and beneficence (do good).
From Vedic point of view, the public perception has rapidly shown a shift from Karma Marg to Bhakti Marg and to Gyan Marg. In Karma Marg, people surrender to the doctor-patient relationship. In the phase of Bhakti Marg, they show faith and Gyan Marg, is marked by suspicion and hunger to know why.
There are four types of patients today based on four levels of awareness i.e. their ability to retain knowledge or information that is given to them by the doctor pertaining to their disease. These four levels of awareness are “ignorant, informed, empowered and enlightened”.
• Ignorant patients do not participate in decision making and depend on the doctor to make their decisions, with no questions asked.
• Informed patients have questions for the doctor, but only few. These patients then usually agree to the line of treatment adopted by the doctor.
• Empowered patients have many more questions, they cross check facts and are an equal partner in decision making regarding their treatment.
• Enlightened patients seek the opinions of many are only then convinced about the proposed line of treatment. Convincing these patients involves several counseling sessions.
There can also be three types of doctors.
• Doctors who expect patients to accept what they say.
• Doctors give choices to patients and ask them to choose.
• Doctors who give choices to their patients, but help them to choose the best option.
Miscommunication is at the root of many doctor-patient disputes. This occurs when the level of awareness of doctor and the patient do not match.
There are also four types of students as per Rabbi Dovid Rosenfeld according to the ability to retain the knowledge taught to them: Sponge, a funnel, a strainer and a sifter.
• The sponge retains everything, but is unable to distinguish between correct and incorrect points. He lacks Viveka, the power of discrimination. The funnel is the one for whom information goes in one ear and out the other. With no focus, his hearing and the mind are in different directions.
• The strainer discards the wine (significant material) and retains the lees (incorrect or insignificant points). He remembers all sorts of trivial or useless details of the material he studied.
• The sieve retains the fine flour (significant material) and discards the dust (inconsequential details). He understands the lecture by its main points and remembers them in the form of sutras.
The principle of “suno – samjho – jano – karo” exemplifies this. This is also the gist of Vedic science and has also been clearly defined in Bhagavad Gita by Lord Krishna. We should hear, listen, understand and convert it into wisdom. Hearing means that you hear anything but listening means that you should learn its meaning. Understanding means you should understand its value in your context and wisdom means you should practice it, re-practice it and learn intricacies of its implications. Once knowledge has been converted into wisdom it is of no use unless it is made use of in day-to-day practice.
Similarly, there has also been a paradigm shift in the accountability for doctors. There was an era when self-regulation in the form of an oath was sufficient (Hippocratic and Medical Council of India [MCI] Oath). As this was considered insufficient, the Code of Medical Ethics Regulations came into force from 2002, which was rapidly followed by Consumer Protection Act (CPA), civil liabilities and now criminalization of medical practice including 304 A.
The Code of Ethics Regulations, 2002 is not simply an Ethics code; it is also about conduct and etiquettes. Unfortunately, ethics, conduct and etiquettes are not taught in the medical curriculum. It is also important to differentiate between unethical acts and professional deficiency.
Therefore, today one is not only required to be scientifically correct, but also morally, ethically and legally correct.
Individual ethics (dharma) or code of conduct (ethics in society) change according to society. Dharma (to hold people together) changes as per the collective consciousness of the people. As people are empowered, ethics will also change.
Disclaimer: The views expressed in this write up are entirely my own.