ETHICS & PROFESSIONALISM

Dr.Jayanti and Dr.Chandrika Rao Faculty: Dr.Adkoli and Dr.Chandrakant Patankar

Ethical education has become the basic requirement for any training programme for health professionals, and should cover the different stages of undergraduate, Postgraduate and continuing education. Both theoretical foundation and practical skills are required for proper ethical reasoning, ethical attitude and decision-making abilities.

What is Ethics?
The word "ethics" is derived from the Greek word ethos (character), and from the Latin word mores (customs). Together, they combine to define how individuals choose to interact with one another. In philosophy, ethics defines what is good for the individual and for society and establishes the nature of duties that people owe themselves and one another Logically derived and based on accepted axioms Eg:Killing is wrong because it violates the inherent tacit agreements of a society.It basically translates to anyone who agrees with the axioms (a self-evident or universally recognized truth; a maxim) and uses a logical thought process Medical ethics is the study of moral values as they apply to medicine and principles that doctors should consider while decision making. In many cases, moral values can be in conflict, and ethical crises can result. Ethics can be regarded as a set of values or principles and duties and obligations, based upon standards of right and wrong that govern the conduct of members of a particular group or profession. Morals -generally considered as being social, religious, or personal standards of right and wrong.[Bledsoe, Volume 1, p. 141]

 In many articles we also come across `Professionalism`. Well, what is `Professionalism`.? Generally, ethics rules tell us what we cannot do and professionalism deals with what we should do.Discussion on ethics in Medicine usually includes `Professionalism`

Ethics studies values and moral reasoning. Non-normative ethics describes and analyzes moral beliefs without making a value judgment about right and wrong. Normative ethics attempts to define actions that are right and wrong. In medicine, the ethical challenge may include deciding between the lesser of two evils or the greater of two goods.

Ethics . The meaning and expression (actions) of values. It is a body of reasons formulated to secure survival (function) in the environment and to rationalize the meaning of behavior. An ethical person is one who is constantly exploring the meaning of values, structure and function

Morals are the values that people use as a meaningful foundation (structure) of their faith, hope and belief to support their behavior toward each other, themselves and the environment in which they live. Values - are the worth of any subject; what you believe that you or others are worth. Worth can change with use and relationships

Medical ethics is the study of moral values as they apply to medicine and principles that doctors should consider while decision making. In many cases, moral values can be in conflict, and ethical crises can result. One would also say, medical ethics is medical morals in an applied form for eg:

informed consent for a trial where ground rules may be laid down based on values and morals as applied to medicine. Well, what is `Medical Professionalism`.?

Generally, ethics rules tell us what we cannot do and professionalism deals with what we should do.Professionalism deals with the entire field of proper behaviour in all respects to a doctor, including trials etc.

Ethics is a subset of professionalism PRIINCIIPLES OF ETHIICS:: PR NC PLES OF ETH CS Six of the values that commonly apply to medical ethics discussions are:

1.Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)

2.Non-maleficence - "first, do no harm" (primum non nocere). 3.Autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.)

4.Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment.

5.Dignity - the patient (and the person treating the patient) have the right to dignity.

6.Truthfulness and honesty - the concept of informed consent has increased in importance

Values such as these do not give answers as to how to handle a particular situation, but provide a useful framework for understanding conflicts.Conflicts in ethical values lead to ethical dilemmas. Many times these conflicts exist between the patient and family, and the medical care providers. Conflicts can also arise between health care providers or among family members of the patient. For example, the principles of autonomy and beneficence clash when patients refuse life-saving blood transfusion.

Ethical Theories or Constructs

Deontology Rules to live by, Conceive of a world where everyone in your situation would perform the action you are contemplating. Is that a good world? Caveat: Never treat an individuals humanity merely as a means towards an end.

Utilitarianism (Mill) Maximize the benefit to all people Perform that action which brings about the most good for the greatest number of people.

Pragmatism (Dewey) No strict rules, the process and developing ones beliefs is important Work through ethical problems over and over again. Each time you work through it, your understanding grows. There is never a right answer.

NoNo system is perfect. Deontologic rules often conflict. E.g.; a patient will not take her medication. The principle of autonomy would suggest that she should decide her own course of treatment, while the principle of beneficence would suggest that you slip it into her coffee while shes not looking. A balance is often most appropriate. Utilitarian principles are often most appropriate when making policy decisions, but deontologic principles must be recognized as well. Different individuals have very different morals/values. Most people function based on their personal or religious morality, not based on a well-developed ethical construct. When differences of opinion arise, attempt to determine the underlying values of the

parties (which often includes yourself and other members of the healthcare team). Find common values, i.e., maxims, and develop from these logical conclusions. Contributors: Dr.Chandrika, Dr.Supe, Dr. Vivek Saoji, Dr. Jayanti, Dr.Stewart.

ETHICS AND LAW ETHICS AND LAW

Though law often embodies ethical principals, law and ethics are far from co-extensive. Many acts that would be widely condemned as unethical are not prohibited by law -lying or betraying the confidence of a friend, for example. And the contrary is true as well. In much that the law does it is not simply codifying ethical norms.Though law often embodies ethical principals, law and ethics are far from co-extensive.Many acts that would be widely condemned as unethical are not prohibited by law -- lying or betraying the confidence of a friend, for example. And the contrary is true as well.In much that the law does, it is not simply codifying ethical norms.Generally, failure to comply with a code of professional ethics may result in expulsion from the profession or some lesser sanction.

Day to day use of professionalism applies to behaviour as in code of medical doctors/ or oath. All cases in medicine which are dilemmas are moral issues, challenging our values and responses. Hence one must see which of the above 6 principles are posing the dilemma and then decide.

WHAT IS ` PROFESSIONALISM `???

Professionalism deals with attitude, values and commitment. It is an essential attribute to the ideal physician and is critical outcome measure for the successful completion of medical school and residency training.

The essential components of Professionalism includes Subordination of ones self interests Response to ones social needs. Demonstration of evincible core humanistic values like empathy, integrity, altruism And trustworthiness. Adhering to ethical and moral values.

There is a growing consensus among medical educators to promote professionalism among medical students. 1. The students should be taught to respond to the societal needs, the responsibilities to their patients, peers and themselves. 2. Qualities such as compassion, knowledge, noble tradition of doctors, obligation to society and respect to humanity has to be discussed. 3. Teach them about the lapses in professionalism that occurred in the past so that we can recognize them and prevent them effectively. 4.Acknowledge the inherent conflict between professionalism and Doctors own financial security and how these issues were dealt in the past and how they will be addressed in the future.

AUTONOMYAutonomy refers to the patients right to make free decisions about his or her health care. It is a patient's most basic right . Respect for persons requires that health care professionals refrain from carrying out unwanted interventions. As such, it is a health care worker's responsibility to respect the autonomy of her patients. However, at times this can be difficult because it can conflict with the paternalistic attitude of many health care professionals.

The Hippocratic injunction "Strive to help, but above all, do no harm" is the ruling maxim. In current discussion, this maxim has been codified in oft-cited "principles of nonmaleficence and beneficence." Although still supported by medical tradition, this ideal physician is increasingly criticized as "paternalistic," too willing to act on judgments of a patient's best interests without the patient's knowledge or consent. To treat without consulting a patient is to assume that a patient does or should share one's own assessment of the risks, benefits, and burdens of treatment. The "neo-paternalists" admit that physicians should attend more carefully to a patient's desires and to give them greater weight in arriving at a treatment of choice. Unmollified critics, however, continue to insist that treatment choice belongs to the patient, however imprudent, and not to the physician, however attentive and knowing. A range of patients' specific rights to be told about, and choose among, alternative treatments, including a right to refuse all, even life-saving treatment has been defined.

As of now, this principle has not been applied to the students. It has been applied only to patient or a person recruited in a clinical trial.

The following case address patient autonomy. This involves the rights of an individual to decide her own fate, even against her physicians' judgments. Case 1: A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, The physicians inform her that the only way to fix the problem is surgically, and that the chances of survival are about 50/50. They also inform her that time is of the essence, and that should the aneurysm burst, she would be dead in a few short minutes. The woman is worried that the surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical treatment. Even after much pressuring from the physicians, she adamantly refuses surgery. Feeling that the woman is not in her correct state of mind and knowing

that time is of the essence, the surgeons decide to perform the procedure without consent. They anesthetize her and surgically repair the aneurysm. She survives, and sues the hospital for millions of rupees. Questions for above case: Do you believe that the physician's actions can be justified in any way? Is it ever right to take away someone's autonomy? (Would a court order make the physicians' decisions ethical?) What would you do if you were one of the health care workers? This is a case vignette.

The major ethical problems faced by the health professionals today include 1. Due to the technological developments, medicine has become very effective, but new technologies have created new ethical dilemmas related to the appropriate use of technology, respect for the patientautonomy, and allocation of resources. 2. Technological development has imposed the fragmentation of the medicine into many specialties and subspecialties and dies not promote the teamwork approach. The advances in intensive care and prolongation of life in organ transplantation have created difficult dilemmas and ethical conflicts for the surgeons.

ETHICS TEACHING TO MEDICAL STUDENTS:

It is a nebulous (and fabulous) topic, with ramification on all aspects of life (similar to the term Brahmaanda in Sanskrit). It is diffcult to think of the issues in isolated pockets. That is how some colleagues have been raising issues like private tution, corruption in examination, charging high capitation etc. etc. May be some had in mind the issue of dowry system (linked to capitation fees), commercialization, down fall of value system in the society, the need for new Avtaar to take place etc. However, as far as medical

education is concerned, we need to address the teaching of ethics, as it is applied for a better patient care. We can consider the issue of ethics in biomedical research and ethics of publication separately if we desire;

Teaching of ethics does not take place in a concerted way as it should happen. To put it in a nut shell:

Ethics teaching can be done only by an interdisciplinary group in a coordinated and phased manner;

Ethics teaching will be effective only when there are good "role models" to emulate; which means that as teachers our primary duty is to practice what we teach;

Workshop approach including case scenarios, role plays, demonstrations and exercises would be of great value in teaching ethics; The workshop can be organized by an interdisciplinary team coordinated by a clinician/community medicine or even a basic scientist with good interpersonal skills;

Assessment should be built in to the teaching of ethics; We need unconventional methods for assessment, like a simulated case, (may be a part of viva exam), check list or observation tool as part of log book, (even peer observation can be thought of), portfolio approach, besides documentation of anecdote/episode in which the student has encountered in his real life situation.

As regards "when" it should be taught, the consensus has been on the phased approach at least on three occasions, totalling 40 hours during UG training

It is very important to reinforce ethics teaching during internship as a part of the interns orientation program which is becoming more popular.

Teaching of ethics, according to me is the essence of teaching medicine and let it strengthen day by day. But remember the realities, it is distressing and scaring. (contributed: Dr.Adkoli)

MAIN 8 QUESTIONS RAISED:

1.Is Ethics and professionalism been taught in your undergraduate classes? Mostly it is not being taught in a organized fashion. Some places like Maharashtra, Karnataka do have a curriculum. Few institutions programme. follow a prescribed teaching

2. Should there be a curriculum for undergraduates to provide skills to recognize, analyze and respond appropriately to the conflicts between professional values and daily pressure of medical school? Yes. Certainly, most of the FAIMERIANS agreed that it is necessary. Most had lot of ideas, a little unsure of what exactly should go into the curriculum. Models of Maharashtra and Rajiv Gandhi curriculum (Karnataka) have been discussed as examples.

3.Can ethics be implemented in Pre, Para and Clinical subjects? Yes. All have listed the principled to be incorporated in their fields, which follow. 4. What are the ethical issues in your specialty? Each has been outlined below as contributed. 5. How should one deal with them?? What are the guidelines laid for them? One can have theory on these topics, role-plays and small group discussions. Student also learns by observation and hence, Faculty training is necessary.

6. What involves or what is meant by student ethics? 7 What ethical principles is involved when medical teachers deal with medical students??? 8 How should we evaluate ethics??

ETHICS IN ANATOMY DR.JAYANTI.V

Elements of ethics commonly found in be instructions to users of Gross Anatomy lab with cadavers Cadaver must be treated as patient. All identifying information about the cadaver must be confidential. Neither the cadaver nor any parts thereof be displayed or positioned in an appropriate, comical or obscene manner Neither the cadaver nor any parts thereof be photographed or videotaped without permission. Parts and the regions that are not in actual use should be well covered and moistened. Inappropriate or improper comments or behavior in relation to the donors will not be tolerated. Fulfill the expectations of the donor and honor their wishes, by dissecting with purpose and respect. Treat the cadaver, as you would wish your own body, or that of a member of your family o be treated Every student should dissect. Cover the face and genitalia of the cadaver and this teaches that the patients privacy is important and the respect for the patient is vital.

Anatomical science is standing right at the entrance of the bridge leading from college life to professional school. We look to transform these individuals who have been care free with little, if no responsibilities into individuals who are entering a profession where there will be responsibility for many important qualities of life. The Gross Anatomy faculty has the opportunity to serve as mentors.

DR.CHANDRIKA LEARNING ANATOMY ETHICS FROM ONCE UPON A TIME. In Padua , Italy , at one of the oldest universities in the world there are three rooms, very different from each other but all displaying a history that the university cherishes

with great pride. First there is the main hall where all the festivities and solemn ceremonies of the university take place. The decoration of the room speaks a strong language in its many symbols: the task of the university is not to take heed of any limits or borders in its service to knowing, knowledge, science, and in the end, truth. In the second room, there is only one item but as it is large and very robust in its form, it captures the attention at once. It is the lectern of Galileo Galilei behind which he gave all his lectures, explaining his observations and building them into a theory that was, gradually, to change the whole view on the cosmos, and the place of humanity within it. And finally, there is a room that is furnished with steeply rising wooden platforms that form the auditorium of an amphitheatre. There is only enough room too stand very close together and steady oneself against wooden railings, and ones attention is drawn to a table in the middle of the room.This is the famous anatomical theatre, the first in the world, where the professors of the medical faculty of Padua revealed the secrets of the human body to their students. The anatomical theatre in Padua is said to have been built upon a subterranean river and the operation table on which the bodies were examined was placed just where the stream had its course. The table was not just any kind of a table but one especially designed for its purpose.The top of the table could be opened by running a small mechanism attached to the table, and whatever was lying on it dropped down to the inside of the hollow table, and because there was no floor underneath, further down until it reached the river and was carried away by the stream.

Why build the anatomical theatre upon a subterranean river, and why design the table as a piece of magicians paraphernalia? These were according to the story necessary security measures to make sure that the study of anatomy could go on undisturbed. The mechanism was put to work whenever the guard outside the theatre gave a warning of

an ecclesiastical officer, a priest, coming to inspect what was going on at the anatomical lecture. To lose a body was a lesser evil than the abolition of anatomical research. It was feared that the influential ecclesiastics would forbid the study of anatomy if they found out that medical teaching and research were based on violating the sanctity of the human body, something the church had defined as sinful and blasphemous. The anatomical theatre of the university of Padua is now a museum. Still, what it once contributed to medical science continues to be valid: the basis of all medical cure and care is the experimental knowledge which has the physical nature of the human body as its starting point. How much of medicine has come from ethical practices and how much have we learnt from others? This is not to support such practices. Elsewhere in the world, like Northern Europe and even in Asia, much of the dissection used to be with the consent of the authorities.

ETHICS IN PHYSIOLOGY
DR.HEMLATA In my specialty ethical issues are concerned with use of animals for undergraduate demonstrations and PG thesis. Use of informed consent when volunteers are used for demonstrations, like BP measurement, reflexes. For animal use there are CPCSEA guidelines, but it all depends on the IAEC members, especially nominee of CPCSEA. For using volunteers, I am not aware of any guidelines for using human volunteers for demonstrations. I have not seen anyone taking informed consent for these activities. PG-seminar on ethics and discussing them during thesis, if it is related to animals. UG, here also we can first sensitize them and then may be one presentation.

ETHICS IN MICROBIOLOGY
Dr. Madan Lal, Microbiology, CMC Ludhiana 1. Communication. Communication of some of the positive results of the investigation such as HIV? AIDS. 2. Informed consent is generally taken for testing of blood or other samples of similar nature. WHO has made it mandatory to take informed consent. 3. Confidentiality has to be maitained by all. Positive results should not become talk of the town. 4.Euthanasia. Leave to relative to decide. Form guidelines as per the need or follow if some official guidelines exists. UGs can be thought by lecturers, group discussions, use of AVAs PGS since they are matured people Role models would teach them ethics even without saying a word. They would learn when they see their role models. DR.AROMA 1) Communication, informed consent, confidentiality are important issues Communication 2 a pt & the attendants about HIV+ve result. 2)Informed consent before doing HIV testing Confidentiality of the report. Along with all these we have 2 report NACO about the actual prevalance without disclosing personal identity. 3)For UG lectures or small gp discussions& for PG seniors themselves act as role models. Case presentation may be mode of teaching.

ETHICS IN PHARMACOLOGY
DR.MEENA

In Pharmacology the ethical issues are:

Ethics in conducting Animal experiments Ethics in clinical research Informed consent in clinical trials

Rational therapeutics. Using the right medicines in the right dose for the given condition at a price that the patient can afford. DR.CHETNA: We have guidelines laid down for performing animal experiments, ICH CGP and ICMR guidelines for conducting clinical trials. We have documents like Essential Drugs List and Standard treatment Guidelines that are based on principles of rational therapeutics and these are our "Bibles" for teaching rational therapeutics to students. 3. In pharmacology we emphasize on the following topics directly or indirectly related to Ethics through lectures, practical, role play, videos and tutorials:

Essential drugs concept How to write a balanced, rational prescription and ability to critically analyze a prescription for irrationalities.

Animal handling How to conduct clinical trials in an ethical manner as per the ICH GCP guidelines

How to assess promotional literature provided by pharmacy companies to learn to look at the irregularities and question their unethical marketing practices.

However these topics that we currently teach are very technical and subject oriented. I would also like to take up those aspects of human behavior that prompt a clinician to prescribe irrationally in spite of having "learnt" otherwise in their UG days...like

monetary pressures, influence of pharmaceuticals, a casual approach and such other issues.

DR.DINESH
In my specialty issues are the written informed consent as we are doing drug trials, use of animals for undergraduate teaching and research work on animals. It is not easy to deal with these issues; it depends on the particular drug trials, animal experiment or research topic etc. There are few guidelines, but these are guidelines only and may be suitable or not. We are teaching our PGs through seminars and actual drug trials.

ANIMAL EXPERIMENTS Dr.SANJAY BEDI`S QUESTION: Can you let me know the current status of doing animal experiments for Post-Graduate Thesis ? What is the MCI Guideline on doing Animal Experiments for the Thesis? Responses: NIMAApart from facilities in the Animal house, proper training of personnel is demanded by CPCSEA If the protocol is prepared properly (taking care of using minimal required number and refined techniques to minimize distress) usually there is no objection. Sometimes nominee of CPCSEA creates problem because some of them do not understand science and research) but nowdays if you have a person from other discipline, you can request CPCSEA to nominate a person with science background.

Dinesh: For MD thesis if there is justification for use of animals they can be used. You need to describe how you calculated sample size(power of study) and all techniques/methods used, euthanasia if will be used, anesthesia, disposal of animal parts or left out,

rehabilitation. For experiments on large animals(dogs/monkeys) permission has to be taken from subcommittee of CPCSEA delhi and for small animals (rodents, rabbits, guinea pigs) from IAEC. Nobody stops u from doing experiments, but you have to take care of the fact that the experiment should be ethically right. There was a misconception that CPCSEA wants to stop all animal experiments. CPCSEA only wants that animals experiments shold be done ethically. CPCSEA is regulating agency for Animal houses of medical colleges and presence of a CPCSEA nominee is a must for all meetings of IAEC in medical colleges. Last month MCI circulated letter of CPCSEA to register all animal houses of medical colleges with CPCSEA.You can refere to book by Maneka Gandhi-Animal laws of India. It has all the details a medical college needs.

ETHICS IIN PATHOLOGY

DR.ANSHU Some of the ethical issues that come to mind are as follows: Hematology/ Cytology/ Histopathology: (a) Informed Consent before doing a procedure: It could be something as complex as a CT guided FNAC, where we do routinely take written consent, or something as simple as taking a blood sample, where we usually don't bother about asking the patient. His presence in your lab is construed to mean that he has verbally consented for the procedure. However, I find it really awkward to note that in most situations, the residents simply ask the uneducated patients from rural backgrounds to sign papers without actually bothering to 'inform' the patient. Quoting from something I read somewhere on the net: If we are to ensure the trustworthiness of human assertion, any deviation from the truth is unacceptable and must be condemned. We are misinformed often enough, blunder often enough, shield ourselves enough and live in deep enough self- imposed shade. We must not add to those forms of distortion by intentionally choosing to engage in deception or selfdeception.

(b) Permission before using photographs for publication: Very few doctors believe in asking patients for their permission to use their clinical pictures for publication. This is unethical and violates the privacy of the patient. However with journal guidelines becoming stricter about masking identity and written permission, awareness seems to be growing in this regard.

(c) Use of human tissues in genetic studies/ cloning: There is a whole world of literature on this and this needs to be discussed separately if you feel it is pertinent to our discussion

(d) Cut Practice: It is not ethical is it to order investigations in a person who doesn't need them, just to get your cut from the pathologist/ radiologist.

(e) Practicing without a recognized degree: As more and more DMLT degree holders profess to be pathologists, the number of wrong reports seems to be spiraling. And most of all I blame the pathologists and clinicians themselves to allow others to practice unethically using their registration numbers.

(f)Who is the owner of the diseased tissue? Once a tumor is out of a body and with the pathologist, is he free to use it for any kind of research without the patient's permission Our guidelines say we need to store the slides for at least 10 years and that they can be disposed off only after advertising their disposal. A patient can claim his slides at any time in that duration.

Autopsy: (a) Issue of consent for complete/ partial autopsy:

Since this is obvious, I am leaving it without comment

(b) Issue of retaining organs: Until recently, whenever there used to be an interesting case during autopsy, we felt free to retrieve the pathological organ and mount it in our museums for teaching purposes. However, this practice of emptying the corpse has been questioned. There was a big furore in the UK recently about a pediatric pathologist who used these organs for research and you can find several detailed articles on this in the BMJ.

Blood Bank (a) Confidentiality of the donor: Donor identity cannot be revealed to the recipient (b) Telling donor about his test results: Until recently, guidelines prohibited us from revealing the HIV, HBsAg and VDRL status of the donor to him. However now some NGOs have mooted the option of allowing the donor to know his results if he wants to do so. No clear guidelines to this effect have come out yet, as a result of which we do get a number of infected professional donors who continue to throng blood banks trying to sell off their blood through unscrupulous means.

3. I believe the best method to influence someone is to practice what you preach. Just like we were enamoured by our teachers who did the right thing the right way, our students too will observe and learn.

However some topics need to be dealt with in a more straightforward manner to sensitize the students. Use of role-plays and brain storming sessions would work best. Ethics need to be interwoven between relevant topics rather than separately dealt with in a separate module.

Medicine is an art more than a science. And in all our specialties we deal with uncertainty. In this situation, how many of us have the guts to say 'I don't know, please consult someone more knowledgeable". In my subject, Pathology, we routinely come across histological specimens, which fox us. And yet, the pressure to deliver a diagnosis is tremendous. There are but a handful of pathologists who have the sense to write, that one needs to consult another more knowledgeable person. In this era of CPA, the tendency to deliver a safe diagnosis is increasing. In my experience, the pathologist I admire the most, (someone I call the prima donna of Surgical Pathology!), Dr Anita Borges, managed to floor me with her frankness. I have seen her sign out a report saying, 'I have performed the following markers, and I am certain that this is not a lymphoma or a carcinoma. However I do not know what this is'! I guess, one will have to reach that stature to be so disarmingly honest!

DR.ANSHU:Comments on `cuts` taken by doctors. I have read the article entitled 'Why I don't believe in referral commissions' by Arun Sheth (1). What struck me as odd about this piece was the fact that we now need to justify the 'right thing to do'. The very fact that doctors who don't give or take 'cuts' are a minority nowadays speaks badly enough of our 'noble' profession. But that we now need to find reasons and justifications for doing the proper things is truly a serious cause for introspection. It appears that a wrong done over and over again by a large number of people, and highly educated people at that, soon becomes the order of the day. Hence, doctors who 'don't fall in line' risk greater marginalisation from the mainstream. They take too long to establish themselves and some finally just give up and change professions. This is especially true for people like us who have dependent practices like pathology.

Let's look at some facts in the pathology 'business'. Technician-run laboratories are prepared to go with technicians, there is no other way because even top consultants

accept these reports (sometimes even unsigned ones) from technicians. We even have a few technicians requesting us to report their peripheral smears or cytologies or even biopsies, which means that even these investigations are sent to technicians' labs and not to pathologists. The flip side is that when it comes to the consultant's own relatives or friends they always come to a pathologist even for the simplest of tests. What's good enough for other patients is not so for the doctor's kith and kin.

Consortium-owned labs or group practice set-ups are the 'in' things. Here, doctors invest money together in a diagnostic set-up and then send long lists of investigations for kickbacks and incentives. (From the layperson's point of view this is viewed as hunting in packs.) I think the main issue here is the percentage receivable, rather than what is necessary for the patient. It is one thing to make a project viable, quite another to burden the patient for your personal gain.

Then comes the choice of the patient to go to any lab. Due to the nexus that exists between the clinics and labs, unless a patient comes back with a report from a particular lab, he is subjected to another battery of tests with the explanation, 'These tests are wrong; why didn't you go to the other lab?' The poor patient fears the wrath of the doctor and does as he is told, in the process compromising his right to choose where he wants to go.

Rickshawallahs and drugstore owners are roped in to direct patients. This absolutely unethical way of 'soliciting clients' just proves to what lengths we are now ready to go to succeed in our profession. It is even more depressing to think how the big reference labs have affected small private set-ups like mine to compete with their prices, especially when nobody cares about the quality of reports that these labs have to offer.

Thus, it is becoming very difficult to practice pathology in a clean manner. It is the patient who is being taken for granted all the time. I have managed so far to keep

myself away from these practices but always get an 'explanation' from my male colleagues that it's because I am a woman and don't have to 'support' a family. I think we must take steps to create a space for ethical doctors to be able to earn a living while practicing their professions with dignity and self-respect. In this, I feel the National Accreditation Body for Laboratories must play an important role and laboratories must be licensed and accredited.

Remember what Gibbon said: 'The first and indispensable requisite of happiness is a clear conscience, unsullied by the reproach or remembrance of an unworthy action.'

Reference 1. Sheth A. Why I don't believe in referral commissions. Issues in Medical Ethics 2003;11:58-59.

ETHICS IN MEDICINE
DR.Himanshu Communication: Failing to communicate regarding the status of a dying patient, failure to explain the disease (in chronic illnesses such as diabetes, nephrotics,celiac disease and many more), failure to communicate the expenses, type of treatment and complications etc. Informed consent: Most of the time consents taken are with partial information, mostly to gain a positive consent. Most of the clinicians inform limitedly about the likely complications of a minor procedure like a lumbar puncture. Consents regarding anesthetic agents used are also not complete. Rare complications are possible and and be considered.

Confidentiality: Though we sometimes discuss cases with each other, I dont think we break confidentiality with attendants (like talking about one patient with parents of another, for eg. Discussing a case of thalasemia in particular with another)

Euthanasia: It is best to leave it to the parents to decide. The routine we follow is to confirm brain death with our possible resources, inform the parents, counsel them and leave it to them to decide. It would be unethical to make a decision for them. Importantly I have learnt to bypass the question what would you do doctor if you were in my place? However, sometimes what and how much to counsel, also is an issue. Besides clarity in the information given is important, all patients are not of equal IQs and their interpretation of our words differ. A very clear explanation may sometimes be interpreted as a doctors advice to withdraw treatment. A discussion on the expenses involved may be an issue with the poor.

Autonomy: Are you talking about autonomy in dealing or treating patients? Well yes that may be an issue, which needs to be thought of independently for different situations and departments. In some places, juniors may not have the independence to decide, though correct. Sometimes, it is to be left on the senior person to counsel or even inform the parents, which may be too late or inappropriate for the parents as seniors are the ones who spend least time with the parents.

Resource spending: resources are limited at all places, be it a private hospital or a government aided institution, there are very few centers in India where you dont have to bother for the money involved when investigating or treating a patient and most of these are research center. My approach is to have the patient in confidence when a special investigation is required, let them know the expenses involved and the final utility of the test for the benefit of the patient.

Of course, a personal judgment of the same should evolve from our own knowledge of the disease and investigations. For the poorer patients sometimes we just need to keep costs at a low.

Another setting that was discussed in some of the case scenarios during the first week is when the expenses levied on a poor patient are too high and another wealthier patient is expected to pay for it. Rather than being the money collector in the hospital, I would rather create a communication between the two or just inform the poorer patient of the available resources. Overcharging the one who affords for the one who doesnt does not seem justified or ethical to me.

You need to formulate your approach and responses to each of the situations depending upon the guidelines and ethics. There must be official guidelines for them, think I need to read more about them. Some general guidelines can be found on the website of the American academy of pediatrics. A website of a journal called Ethics can also be of help.

For undergraduates, some didactic lectures, group discussions would be of use. Using roleplays, case scenarios for group discussions or even use of video clippings would be good.For postgraduates, essentially we need to provide role models in our own behaviours and actions.

ETHICS IN PEDIATRICS:
DR.Chandrika Rao In children, they are the recipients of their parents decision and hence it is very important. The patients themselves have limited life experiences and are

developmentally unprepared to make decisions about their care. Instead, pediatric patients depend on their parents or another authority figure because young children often cannot understand what is best for them or the ramifications of their actions. Their immaturity and vulnerability create a different decision-making context than that of adult patients. The problem of informed consent

With adults, the principle of autonomy is the focus of consent, meaning that patients have the right to make their own decisions. In child or adolescent patients, the circumstances are more complicated. Legally, parents or legal guardians have the right and responsibility to give (or withhold) consent for procedures or treatments. Involvement of the child in a developmentally appropriate fashion in the decisionmaking process is also considered the ethical responsibility of the physician. Best protection for the child The process of determining the best course of therapy involves setting both short- and long-term goals, recognizing the specific values of the child's family and maximizing opportunities for the child to grow, develop, and realize his or her fullest potential. Ideally, both the parents or legal guardians and the physician should approach the issue of consent from this perspective. However, sometimes, the legal guardians or even the physician has competing interests. In those situations, special care should be taken to keep in mind at all times what is in the best interests of the child. Examples of this kind of problem are when a family is strained financially because of the costs of the child's medical care or feels that siblings have been neglected because of the time required by the sick child. Physicians as advocates Decisions about the best course of therapy for a child often involves a childs social structure, environment, and parental involvement. The physician is placed in the role of an advocate for the child. Although this advocacy role is somewhat uncomfortable at times, it is one of the features of medicine as a profession, rather than the merely technical exercise of human body repair and maintenance. The potential adult

Children should always be treated with an eye toward their eventual adulthood. As they mature, children naturally gain increasing responsibilities for decision-making and self-expression. Medical decisions are no different. Clearly, by age 13 years, most patients should be able to understand the basic aspects of their disease process, participate in discussions about therapeutic options, and express their preferences about treatments. Although older children remain emotionally and financially dependent on their parents, physicians should respect their increasing autonomy by involving them more in the decision-making process. Exceptions to parental decision-making Substance abuse, mental disability, or immaturity may make a parent incapable of providing informed consent. In these cases, clinicians should seek a court-appointed guardian. In other cases, parents disagree with one another. While only one parent is usually required to sign in agreement for a medical procedure or treatment, turning to the other parent for consent and then automatically proceeding ahead when one parent has already refused is not considered ethical. The physician might talk with the other parent about the issue but would need to involve both in any change of decision. Emergencies Situations when the child's life is in imminent danger and the parent cannot be informed should be treated with bias toward preserving life and limb at all cost. To ensure that the child's best interests are served, erring on the side of treatment rather than foregoing treatment is appropriate. A typical example is trauma surgery for a child injured in an automobile crash in which the parents are also injured and unable to respond. Adolescent patients

In the United States, persons aged 18 years are legally considered adults and can generally provide informed consent without parental approval. The American Academy of Pediatrics recommends that physicians obtain assent for health care decisions from children aged 13 years and older. Between age 13 years and legal adulthood, pediatricians should evaluate the child's ability to understand and provide informed consent. Emancipated minor Adolescents who clearly live without parental support can be classified as emancipated minors. Evidence of emancipation includes living apart from parents, managing one's own finances, marriage, bearing and raising children, or serving in the armed forces. Specific exceptions Most states allow a minor to consent to treatment without parental involvement for sexually transmitted diseases (STDs), contraception, and pregnancy. The assumption in these instances is that requiring parental involvement deters the child from seeking treatment. Some states also allow diagnosis and treatment of substance abuse and mental health disorders for older adolescents without parental consent. Disclosure of information to children Children should be provided information that is presented in an age-appropriate manner to help them participate in decision-making. Parents sometimes hesitate to share information about a serious diagnosis such as cancer or HIV infection. The pediatrician should anticipate parental fears and concerns and help them understand that their child can better cope with the illness when truthfulness and trust are maintained. Helping them plan what they will tell their child or even role-playing the telling is often helpful. Confidentiality

Physicians should maintain the confidentiality of pediatric patients as they would any other patient. In cases that involve pediatric patients, the surrogate decision maker or guardian is the person to decide with whom the information may be shared. Adolescents can request confidentiality, even from parents or guardians, in specific cases, such as pregnancy or STDs. In these cases, the physician should encourage the patient to discuss the situation with a responsible adult friend or family member. When family rights and public health needs conflict: Parental refusal of immunization of children Parental refusal to vaccinate a child is a special challenge. In this case, the gains and risks for the individual child need to be weighed, as well as the public health risk an unvaccinated child poses to other children. Ky considerations include whether the parent withholding immunizations from their child harms that child enough that their decision constitutes medical neglect. Equally important is whether their failure to immunize their child puts others at risk enough to constitute a significant public health issue. Ref: Bioethics in Pediatric Practice-Author: Linda Grossman, MD, Division Head, Associate Professor, Department of Pediatrics, Division of Behavioral and Developmental Pediatrics, University of Maryland School of Medicine

TUITIONS AND MEDICAL TEACHERS

DR.ANSHU It is a shameful fact that medical teachers in India have resorted to taking tuitions for students in large numbers. These teachers hardly teach properly in their classes, yet have hordes of students parking their vehicles outside their houses in the evenings. The students who participate in these coaching classes get more marks in the practical courtesy these money minded teachers- which translate into secure PG seats (which has been partly controlled by introducing entrance examinations). I fail to understand how

a subject like medicine can be taught in the privacy of homes without a patient being examined. DR.DINESH We dont have this problem right now, but in few institutes where NRIs admissions are there this trend is starting here also. I know one institute where NRI requested tuitions through college administration. They were allowed initially, but later on this decision was reverted back. This creates a division between students. Students taking tuitions automatically become favorite of that particular teacher. It is not an ethical practice DR.MONIKA Two private practitioners (one a peds surgeon, another a plastic surgeon) took it on them to teach surgery. They were reputed to teach well and actually taught us more than just general surgery. But I don't think my concepts in surgery are any better than those in med or gyne, just because I had 'tuitions'. I cannot comment if these tuitions are unethical, but they definitely provide least help in clinical skills and stress more on the theories. But in places where these tuitions are rampant, are the teachers in med college to be blamed for not reaching out to the students?(we didn't have any formal teaching schedule in final year, that is what attracted us to these 'tuitions')

ETHICS AS EXAMINER
DR.ANSHU I am examiner for a few universities. And one of the lines that catch my attention every time I have to sign a consent form to take an examination is, 'I have not written a textbook or guide in my subject'. How does writing a book disqualify me from becoming an examiner? Does it mean I know more than necessary?!! Or does it mean that students should not read my book?

And if the University as part of the syllabus approves that textbook, will I still be ineligible to become an examiner?

REVEALNG GRADES/MARKS TOSTUDENTS Should the marks of a student be displayed to all?

DR.ANSHU The issue is not as simple as it seems. While having transparency in giving marks is imperative, it does have a psychological impact on those who fail or don't do well. While seeing where one's stands helps in boosting or encouraging one's effort- it tends to depress the slow learners. If however marks are not overtly displayed, all too often we see children of staff members/ doctors being showered with marks that they do not deserve. Dr Sanjay Bedi feels if marks are displayed along with returning answer sheets it brings transparency as well as better results.

DR.STEWART In New Mexico, each student receives a personal ID number each semester and grades and scores are posted for all to see results but each student only knows their own score. In this way, they can see the results and their own performance in the total perspective. DR.DINESH I think it is unethical if we do not provide marks, it is important tool for improvement through feedback. The problem of doctors kids getting higher marks if they do not deserve, is to be solved entirely by dept. In our university this session it is compulsory to put marks of internal assessment onboard 1 week prior to theory examination. We have to put also details how these marks were calculated, as per university rules we put them into 3 categories.

It is very essential that we provide all marks to students. One cannot tell a student in the end that he/ she is ineligible to appear for exams because of low marks. If u starts displaying, right from the first test, then u can give feedback to them and they get time to improve. I personally feel it is unethical not to display their marks.

DR.TEJINDER SINGH Being father of two kids studying in medical school, I am tempted to add a line. While it may be true that some people may be influencing colleagues to give higher marks and vice versa, at the same time, all doctors' kids should not be suspect, simply because their parents happen to be medical teachers. It is a matter of individualism and no generalizations can be drawn. In our own school, there are examples, where children failed a year in spite of both parents being senior faculty!! TS DR.ADKOLI My first response is that if the primary purpose of assessment is to help a student in learning, revealing marks is not only desirable, but essential too. For a student to improve further, he needs to know where he stands, what went wrong, where others did right so that he gets useful feedback. Feedback according to me is more than revealing marks; it should also indicate what was the expected answer according to the marking scheme pre-determined by the paper setter/examiner;

Knowing the marking scheme/scoring key is the birth right of a student. However, I remember having a fight with some of my esteemed colleagues who argue that in medicine there is nothing like correct or incorrect, hence they cant' give the marking scheme! May be they are right, but as an educationist, I feel a question which cant' be judged as correct or incorrect is not worthy to be asked. I don't believe in asking any thing which can't be quantified. Keeping the correct answer to the imagination of

student/examiner defeats the very purpose of examination. Transparency is the bottom line of any examination system. This does not preclude your right to assess the candidate on the aspects, which require subjective assessment (e.g., originality, creativity, honesty, integrity and many other important attributes, which we wish to include (which are unfortunately not included now). Now coming to the issue of ill-effects of the revealing on the poor students, some thing should be done to counsel them, boost their morale, and impress them that the marks is not reflection of their "inferiority" but their performance on that occasion. Don't you see such comments made by the Judges to the "well tried but failed" candidates in our high stake TV competitions (Indian Idol/Mahayudh etc.)? DR.HEMLATA Think it is not right to say that someone cannot display marking scheme because it cannot be done in his or her subject. The first principle of evaluation is it is measurable. If it is not measurable, hen the method a lacks a substance. I completely agree with Dr Adkoli that you must inform kids about their performance and give them a chance to improve. Our dept is doing that regularly, now we are even displaying internal assessment in detail with formula. DR.ANSHU Children of faculty had to work harder than normal kids to prove their worth, and even if you did do well, people would smirk that they got those marks because `so and so` was the Principal. The only chance to prove your critics wrong is to excel in the Board exams. Biased teachers and behind the scene politics perhaps would deliberately deduct marks where one deserved them, and teachers who wanted to be in good books, would give more marks than one deserved. Even in medical school, I do find certain colleagues pressurizing us to see that their kids top, and even if they don't do that, the seniors percolate that myth that this needs to be done. The moment you are appointed examiner, your phone starts ringing with

roll numbers being dropped. And like me, I do sympathize with the staff kids who are really good and have to be the victim of taunts. Worse, I feel really sorry for kids who are forced into medicine, without the slightest interest in the subject- just because their parents are doctors. DR.CHETNA Discrimination by teachers and colleagues on basis of community, region and often-on personal bias and dislikes is a very common behavior. Remember, the smartest kid in KG gets to say all the poems, is made the monitor, while the one with a runny nose usually sits in the background. A few years on the student who gets the roses/cards for the teacher is the favorite. Those of you who grew up in so-called cosmopolitan environments would also have "felt" similar vibes of regionalism if you belonged to a "minority". The point is that adults and teachers we forget to leave such conditioned behaviors and continue to do what our teachers and elders did. I personally feel that the head of the institution plays a major role on what direction the institute takes on such matters. It should be a policy of the institution rather than the whims and fancies of some students groups or faculty. Chetna

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES --ETHICS RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES ETHICS CURRICULUM CURRICULUM
SYLLABUS 1. Intro to Medical Ethics: What is Ethics? What are the values & norms?,Relationship b/w being ethical & numan fulfillment.,How to form a value system in ones personal & professional life? Heteronomous Ethics & Autonomous Ethics.,Freedom & personal responsibility.

2. Defn of Medical Ethics: Defference b/w medical ethics & bio-ethics Major Principles of Medical Ethics, Beneficence=fraternity Justice=equality, Self determination(autonomy)=liberty 3. Perspective of Medical Ethics: The Hippocratic oath.,The Declaration of Helsinki, The WHO Declaration of Geneva, International code of Medical Ethics(1993),MCI Code of Ethics(2002) 4. Ethics of the individual: The patient as a person,,The Right to be respected,Truth & Confidentiality The autonomy of decision,The concept of disease, health & healing The Right to health,Ethics of Behaviour modification,The Physician-Patient relationship,Organ donation 5. The Ethics of Human life: What is human life?,Criteria for distinguishing the human & the non-human Reasons for respecting human life,The beginning of human life Conception, contraception,Abortion,Prenatal sex-determination IVF,AIH,AID,,SIFT,GIFT, ZIFT,genetic Engineering 6. The Family & Society in Medical Ethics: The Ethics of human sexuality FP perspectives,Prolongation of life,Advanced life directives-The Living Will Euthanasia,Cancer & Terminal Care 7. Death & Dying: Use of life-support systems.,Death awareness,The moment of death Prolongation of life,Ordinary & extraordinary life support Advanced life directives,Euthanasia-passive & active,Suicide-the ethical outlook,The right to die with dignity 8. Professional Ethics: Code of conduct,Contract & confidentiality,Charging of fees, Fee-splitting Prescription of drugs,Over-investigating the patient

Low-Cost drugs, vitamins & tonics,Allocation of resources in health care Malpractice & Negligence 9. Research Ethics: Animal & experimental research/humanness Human experimentation,Human volunteer research-Informed Consent Drug trials 10. Ethical workshop of cases: Gathering all scientific factors Gathering all human factors Gathering all value factors

EVALUATION Atleast 1 Short Answer may be asked on medical ethics appropriate in all major subjects in university written theory exam. A few questions may be asked during VIVA exam

Objectives: 1. Identify underlying ethical issues & problems in medical practice. 2. Consider the alternatives under the given circumstances, & 3. Make decisions based on acceptable moral concepts & also traditional practices. Theory: Professional relationship Patient-doctor relationship Issues @ the beginning & end of life Reproductive technologies Resource allocation Health Policy. Values, Ethical concepts & Principles. Clinical ethics: (From Bedside group discussions, case studies, problem analysing & Problem solving

exercises): How to identify & resolve a particular problem? Awareness & knowledge of value dimensions of interactions with the patients, colleagues, relations & public. Development of skills of analysis, decision making & judgement. Aware of the need to respect the rights of the patient as also duties & responsibilities of the doctor MEDICAL ETHICS-RECOMMENDED HOURS Phase-I: 6 hrs 2hr each by Anatomy, Physiology & Biochemistry. Phase-II: 6 hrs 2hr each by Pharmacology, Pathology & Microbiology. Phase-III(Part 1): 8 hrs CM: 4 hrs 2hr each from ophthalmology & ENT. Phase III(Part 2): 20 hrs. 2hr each in Medicine, Surgery & OBG in each of 6th & 7th terms=12 hrs. 8 hr from other clinical depts. TOTAL: 40 hrs. *Medical Jurisprudence by FM. Recommended books by RGUHS. 1. Medical Ethics, 2/e, 2004, by C.M.Francis. 2. Ethical Guidelines for Biomedical Research on Human Subjects, 2000, by ICMR ********************************

ETHICS,,DOCTORS AND PHARMACEUTICAL INDUSTRIES . ETHICS DOCTORS AND PHARMACEUTICAL INDUSTRIES

DR.ANSHU

The pharmaceutical industry never loses a chance to advertise its stuff. And so it is shocking to see how far doctors can bend to get a drug company sponsor a free lunch, a CME or a conference. There are no free lunches. The Pharmacy industry extracts its pound of flesh for them in any case. Sevagram, has spurned all kinds of sponsorship from the Pharmacy companies since 2002. The funding for organization is raised from the registration fees and the management. And if a small college like ours can hold international meets without sponsorship, so can the rest of you. Quoting Adriane Fugh-Berman and Sharon Batt. from Ethics J Am Med Assoc 2006; 8(6): 412-415. "Several years ago, the Mahatma Gandhi Institute of Medical Sciences, a rural medical college in Sevagram, Maharashtra, India decided to refuse drug industry support for any conferences, seminars or workshops; thus becoming the lone medical college in the country to keep (the) drug industry away from medical education. Surely, if a medical college in India can afford to scorn the bribes of pharmacy, one medical school in the USA could show the same leadership." DR.DINESH Is it so easy to avoid med reps? Pharmaceutical Industry has multi-track approach for providing information to physicians. 15-20% of budget of a pharmaceutical industry is for promotion of products. Out of those > 50% is spent on medical representatives. 90% of the physicians see medical representatives. This is the easiest way to gather new drug information. A substantial percentage of physicians heavily rely on representatives as source of information about drugs. Medical representatives are criticized a lot, but there network is very huge and now they have become an integral part of medical infrastructure in the country. Hence make best use of this huge network for getting drug information in a desirable way!

Ask about publication of drug safety in an authentic journal. Optimize the time spent with medical representatives. Remember following points while dealing with a representative: Take control of the discussion You get the information you need Ask for officially registered drug information and compare it with what industry has got printed Comparison with standard treatment use Particularly look for side effects and contraindications Ask for published references on efficacy and safety If it is 'me too' drug (analogue of same class e.g. new proton pump inhibitor) ask about price Do not start by using free samples on a few patients or family members Do not base your conclusions on the treatment of a few patients Accepting gifts may not be a good idea, but if by accepting gifts you start influencing the medical representative. I mean to say try to change his attitude (in a short time), tell him where he is wrong, tell him you will accept next pen only when he provides authentic gift.

DR.MONIKA One of the reasons why medical representatives are disliked is that they often provide very biased information in favor of their own products. Easiest way of staying out of this enticing net is to be well informed yourself, though reps may be a source of information regarding 'new arrival on the stands', it is the doctor's responsibility to get the final information first hand rather than rely on what reps have to say.

At the same time I do not agree with doctors who will show the medical representatives the door just because of their views against the principal of medical representatives. I wouldn't mind accepting a petty gift of a ball pen in an outpatient, because turning it down would only hurt them and may even disturb his moral (most of the reps are very young......I don't consider shutting them up by a 'smart' doctor wd help build their professional confidence) well this is my personal opinion and is similar to my attitude towards a guest coming to my house.....even if I hate him I will just smile and tolerate him. I strictly dislike medical representatives promoting ayurvedic and naturopathy drugs, but just listen to them for the heck of it. DR.ANSHU and Dr.Payal No- it isn't easy to avoid medical representatives at all. But we need to draw the line of where we need their help. Do use them to get drug information but never forget to use your critical analysis to question what you are being fed. I have heard too much about ghost written articles from pharmacy companies to be complacent about them. Quoting from Chandrika's 'Survival of the fittest' mail: "What they should understand is that even apparently trivial gifts can influence doctors judgment and, subsequently, their behavior. Its a major goal of pharmaceutical salespeople to establish a close rapport with their doctors. Alliances are forged and cemented primarily by a constant flow of gifts, large and small free samples, pens, food, clothes, books, luggage, crystal bowls, tickets, money and expensive travel. The list is virtually endless. From the time we are residents in training, the shower of coffee mugs, penlights and expensive textbooks, teaches the young doctors that accepting gifts from the drug industry is a normal part of professional life. Medical school is where it begins, but scarcely where it ends. " When one is obligated to another person, howsoever trivial the gift is, you lose a part of your autonomy. So please think before you leap. DR.CHANDRIKA Speaking of, Doctors, drug companies, and gifts ,

The pharmaceutical industry appears to be asserting increasing influence over medicine. Much of this influence occurs at institutional and systemic levels. They may meet with sales representatives, dispense drug samples, attend industry sponsored educational events and accept gifts. In other words, by accepting gifts, physicians sell a small piece of their professional autonomy. Empirical evidence shows that both doctors and patients are naive in their assessment of the biasing potential of gifts What they should understand is that even apparently trivial gifts can influence doctors judgment and, subsequently, their behavior. Its a major goal of pharmaceutical salespeople to establish a close rapport with their doctors. Alliances are forged and cemented primarily by a constant flow of gifts, large and small free samples, pens, food, clothes, books, luggage, crystal bowls, tickets, money and expensive travel. The list is virtually endless. From the time we are residents in training, the shower of coffee mugs, pen lights and expensive textbooks, teaches the young doctors that accepting gifts from the drug industry is a normal part of professional life. Medical school is where it begins, but scarcely where it ends. From the companys perspective the social fabric of doctor-industry exchanges exists to generate unnecessary or inappropriate prescriptions. When the drug rep becomes your pal or buddy this commitment can generate serious risks and side effects for patients Of course, very few doctors would intentionally prescribe inappropriate or inferior drugs for their patients. But studies demonstrate clearly that when doctors have been treated to a round of golf or a fine dinner they are much more likely to prescribe the products of the company which paid for these treats, even when scientific evidence points in a different direction. Physician bias is almost always unconscious and unintentional. Its effect is morally insidious, however, because it can easily result in serious harm to patients. To honor

their vow - The life and health of my patient will be my first consideration - doctors must conscientiously avoid making themselves beholden to companies. We require the doctors to buy their own meals and pay for their own fees and travel. The moral cost of the free lunch is too high. Medical colleges and teaching hospitals are one important venue for these issues to be debated and for professional attitudes to be shaped. Reference: Professor Schafer is Director of the Center for Professional and Applied Ethics, at the University of Manitoba . His article, Biomedical conflicts of interest is published by The Journal of Medical Ethics. Schafer@cc.umanitoba.ca

DR.CHETNA You will all agree that most conferences and workshops of clinicians are glamorous with lavish gifts, great dinners, even musical programs and what not. Lately its come to focused small group entertainment to a select few "heavy weight" prescribers. The magnitude is enormous in private practice as compared to the hospitals like ours. I had the opportunity of organizing 2 state level conferences in Pharmacology and am an active team member in a few other national and state levels too. A common denominator while organizing these was the lack of adequate funds. No pharmacy company would come forward freely with advertisements or even if they did they would insist on including a lecture by their speakers. We then had a couple of approaches:

We roped in our own ex faculty or students who were willing to contribute without strings attached

We lowered our requirement of adequate funds and cut down on expenses. Roped in well wishers who donated for an academic cause.

DR.TEJINDER SINGH Want to share a psychological experiment conducted few years ago in USA. During a movie show, 'eat pop corn, drink coke' was flashed for a millisecond on the screen-

short enough for the human eye or brain to register it. However, it did result in a significant increase in the sale of these two items in those movie halls. The power of suggestion is great. We may not get influenced to write, for example, a costly drug to a patient- but when it comes to decide between brand A or B of the same drug, the subconscious mind works! This is the basis of all advertising and pharmacy advertising is no different

DR.ADKOLI Pharmacy-nexus is causing a great dilemma in the mind of organizers, delegates and sponsors. The problem is akin to sustainable development issues, in which life style improvement conflicts with destruction of eco-system. The sponsors, especially the pharmaceuticals are too willing to sponsor "scientific conferences & CMEs" targeted to sell their products, for purchasing the good will of the clinicians. The clinicians think that they should do full justice to the delegates by throwing a gala bouquet dinners, and filling their conference bags with full of gifts. The delegates also expect a lot of luxury and comfort, attach more value to the "frills and thrills" rather than the "skills" of speakers, as long as they don't pay the "bills". The commercial implication, boost to tourism, and allied activities is another issue. What is the answer? The solution lies in self-restraint, simplicity and sincerity to conquer glamour, show-off, and false prestige. The organizing committee can make a conscious effort to scale down the "masala" of the "khana-wana" and add more "masala" into the "Scientifics" which doesn't cost a penny. We may also contact sponsors and friends who do not expect any thing in return. A lot of voluntary organizations and charity institutes would like to help out for a cause. In India, the concept of "paying for CMEs has not yet taken off. CMEs should be organized in such a way that they can be sustained even without sponsorship. Trace out faculty who can accept modest hospitality rather than five star luxury. If you can do it for your friend once, he/she will reciprocate for you certainly.

Coming back to the training of new doctors, I remember, in NTTC, JIPMER, Pondicherry, during interns orientation workshop, we used to have a role play of a MR and Dr in which MR traps the Dr who is stage set for organizing a conference. It used to work very well. But now I feel that in role plays we usually show "what should not be done" rather than "what should be done". Think of role models rather than role-plays, because facts are more relevant than fiction.

DR.CHANDRIKA I have attached the guidelines for gifts to be accepted by doctors. Excerpts: In the January 19, 2000 edition of the Journal of the American Medical Association, Dr. Ashley Wazana revealed that while 85% of medical students believed it improper for politicians to accept gifts from lobbyists, only 46% thought it improper for doctors to receive gifts from drug companies. Evidently, while they distrust the ability of politicians to remain uninfluenced, they do trust themselves to be free of such burdens. Questions raising doubts of many accepted daily practices are uncomfortable, but ethical questions often are - and they may be more uncomfortable for physician. About books, the article says: We have increasingly questioned the appropriateness of some of the gifts that are given to physicians by companies in the pharmaceutical, device and medical equipment industries. Many gifts serve an important and socially beneficial function. For example, companies have long provided funds for educational programs and facilities. Some gifts, however, may have inappropriate effects and are therefore cause for concern.

ETHICS AND ABORTION ETHICS AND ABORTION

DR.CHANDRIKA I am glad the topic of kidney transplantation has come up. There are a lot of ethical principles which have to be thought of, some of which have been legalized. Other areas of ethical dilemma that exist is the principle abortion.

Abortion is a very controversial subject that has been continually argued over for the past few years and probably many years to come. There is no real answer to this controversy; there are two sides to it, which has been argued for many years over the subject. Abortions are carried out worldwide with varying degrees of legality. The two main groups involved in the debate are the pro-choice movement, who generally support access to abortion, and the pro-life movement, who are opposed to abortion and its general availability.. Ethics goes beyond what is or can be legal to what should be legal. In ethics, rights have no connection with legal documents, like a constitution, but are presented as inherent. Regarding abortion, the ethics debate usually surrounds whether an embryo has rights, and whether those rights should take precedence over a woman's. Best conclusion to the abortion controversy is that although abortion is morally and ethically wrong, there are no real alternatives for those who are victims of rape and such crimes. That is why the best solution to this controversy is to legalize abortion for those who are victims of these crimes. There is no end to the subject and many guidelines exist on this

Etthiics and gender E h cs and gender

Dr.Anshu There were open comments from the senior faculty that girls could not occupy the top posts as they had already two toppers as class representatives and two posts of ladies representatives in the panel and they could not handle pressure like the guys. Why should girls be punished for topping exams? Strangely, such comments never arise when the boys top exams. I personally feel the post of ladies representatives should be abolished or 2 similar posts for male representatives should be introduced. While I strongly feel that the kind of people who were finally selected into the Council were the correct and deserving ones, the manner in which a student is sidelined just because he belongs to a particular state, community or gender- leaves me hurt, troubled

and pained. We give in to stereotypes painted by the media and our colleagues. Why should one be denied the chance to participate simply because his/ her origins do not suit your mental make-up? It wouldn't matter to me, if those students had come to the meeting and democratically lost the posts. But simply painting a whole group black because of your previous mental baggage is completely unfair. I was reading dilemmas in student ethics and I think the term for this is 'social group relativism'- If the action conforms to your social group's norms, then it is right. If it is contrary, then it is wrong'. DR.CHETNA The issue of female feticide is more social than legal. In fact as they say.....laws are meant to be broken and can be broken by one determined to do so. Construction of and implementation of laws for the same can help, but this affect is likely to be ill-sustained and effective on the surface only. For eg. the law that prevents sonologists from sex determination SEEMS to be very effective. Sonologists in medical colleges and larger set ups(who have earned more than they needed already) will not determine the sex or will put up a poster saying that 'SEX DETERMINATION IS NOT DONE HERE'. Who says it is not being done under cover? What we need is more than a mere law...we need a moral and social change in view point! Give girls the equal opportunity to excel...equal opportunity to study...to work.........to be named as the gaurdian of her own child......to take care of her own parents like males do.....why can't the eldest daughter be considered the heir........as they say in hindi...'vanshaj'...and take the family name......etc. well, the speech can go on........but it seems long before the moral uprising will appear! Gujarat university allows for free education for girls...I paid 350 a year in pg while my male counterparts paid more than 3000.....that did not ensure a greater no. Of girls in med school, we were only 30% of the class. Change should begin at the beginning... A new tree does not grow on branches.........it starts from the roots.

DR.ADKOLI

I share your view points, and deep concerns. Gender discrimination is indeed a chronic ailment of the society, which has implications for sustainable development and ultimately the preservation and perpetuation of the human race. All of us are also aware of the fact that in a land where women are deemed to be worshipped ( Sanskrit Quote: Yatra Naaryastu Poojyante, Ramante, tatra devataha-meaning, Where women are worshipped, Gods dwell), female infanticide, foeticide, and bridal burning make biggest news coverage. Are we heading towards destruction of balance in the ecosystem? Who are responsible for this? What can we do to address this issue? The issue is multi-dimensional and multi-factorial; we are collectively responsible for this tragedy. We need to address ourselves first and then the society and the communities at large. Fortunately, being medical professionals we have a "say" in this matter, our voice is at least heard, some times listened, and a few times taken seriously. We have to cash on this asset. Our agents of change are our young doctors. If they can be molded to act as role models, we can expect the society to make some strides. Some efforts are on the way to infiltrate information about gender issues in the curriculum (Dr Malati Ramanathan, from Sri Chitra Tirunal Instt., Trivandrum, has been working in this area). I would rather emphasize the role of Co-curricular activities in imparting the knowledge and shaping attitude. Earlier they were considered as "Extra"-curricular activities, but now they are very part of the curriculum hence the term "Co-curriculum". You can think of cultural festivals, community activities, street plays, puppet shows, quiz, debates, mimes, and what not. The students during the community/field projects may be encouraged to put up cultural activities that can make impact. Our media especially the big screens and small screens can play wonders with the kind of talent that the medicos are; The answer therefore lies in "Social activism", which is behind and beyond routine teaching of medicine. If a bad doctor can kill hundreds and a bad trainer thousands, why not a good doctor motivate hundreds and a good trainer convert thousands?

DR.CHETNA Gujarat is currently seeing a movement against female foeticide. Prenatal sex determination is banned and some USG machines of radiologists have been sealed when they were found guilty of the same. Recently a "busy" radiologist out here had his machine sealed. During the discussions that followed among the medical fraternity, it was perturbing to know that this step against the erring doctor was considered asharassment" so that money (bribe) could be squeezed out of him by the authorities. Bribe or no bribe, our learned colleagues failed to appreciate that there is no smoke without fire and if the sonologist was indulging in this kind of misdoing he should not be condoned, ethically speaking. It requires a lot of courage, objectivity and passion to speak about and expose fraudulent behavior in our colleagues.

Physiiciian Referralls:: Phys c an Referra s

DR.MONIKA Though rules exist on paper, how many of us follow them. One of the rules I read with interest was conduct of a doctor when giving a consultation to another doctor's patient. Every single rule can be seen violated daily. Whenever we send a consult for a superspeciality, while I would like and expect to see the consultant giving valuable guidance to treat the patient, the advices are usually laced with criticism regarding the treatment being given, junior doctors scolded for things they cannot explain, one of our super specialists has on occasions refused to see particular patients because you pediatricians are spoiling patients...you don't listen to me' etc. His newer trick is to write transfer patient to our side' and when it is not done...he refuses to see again. One statement that I find arguable is "strive to expose those physicians deficient in character or competence, or who engage in fraud or deception." DR.CHANDRIKA If you strictly consider ethics and the principle of ` do no harm` exposing those physicians deficient in character or competence

has to be done to avoid patients being hurt or wrongly treated. It is also justice to society. However many of us shy away from doing it due to the ramifications from our own colleagues

STUDENT ETHICS STUDENT ETHICS

Medical college involves a lot of dedication and hard work. As a medical student, one is required to attend lectures, labs, and activities daily, while nights will be spent studying. One should expect long hours! Cramming is impossible in medical school since the amount of information to memorize is endless. Medical college is not easy. Therefore, hard working students, who are capable of dedicating their lives to studying, are more successful. Competitive students are more likely to survive medical school. However, a fear of not being able to save a patient is what strives medical students to stay focused. All students who enter medical college may not be prepares for this. They may opt ways to decrease the workload and employ unethical behavior. Egs could be: 1.Copying a classmates homework 2. Giving a professor a gift in order to win his or her favor 3. Being given material from a friend who already took the class one is currently taking 4. Lying to a professor. (About getting an extension, why one has turned in an assignment late, etc.) 5. Doing special favors for a Professor without compensation 6. Plagiarizing (taking someone elses work and called it ones own) ETC Some may not even sound odd to the student. Apart from ethics as applied to medicine we need to inculcate ethics in student learning medicine in the proper way too. I have two problems which could illustrate what I meant:

Problem::

Cell Biology professor assigns a problem set. It is not clear to the class whether the assignment will be graded, but it is clearly required.. Two students work together on the problem set. The third student, Miss Conscience, feel uncomfortable about their joint effort and works alone. On the next class day, Conscience notices two other students copying the problem answers from yet another student just as the class is beginning. Miss Conscience is furious about all this behavior, but says nothing. Later in the year, during a meeting with her Advisory Committee, she complains that there is much cheating.

Are the students who worked together at home wrong? Are the students who copied the problem in class wrong? Is Conscience wrong in her delay in confronting/reporting? What about the professor's responsibility? What is an "honor system"? Would one work here? If the answer is "no" then how can we trust research conduct?

Problem 2 Ten graduate students are enrolled in a course in neuroendocrinology that is also open to other students , and many of the latter group have taken the course in recent years. They have heard from their friends at their colleges that the professor gives the same test questions year after year. Indeed, there is a file of old exams at ABC College. Two of the students from ABC use that file, unbeknownst to the XYZ students. Finally, after the end of the course, one of the XYZ students finds out.

What should the student do?

DR.SANJAY Student Ethics means the behavior of students towards teachers themselves and the Institution they serve the University they are affiliated to. Quite often students run to teachers with parents crying to get their attendance improved. I remember a student who could not get enough marks in internal assessment. His attendance was mere 5%. He went to court that the teacher is biased towards him and even involved the teachers

family in the wrangle just to harass the teacher to give in and change the internal assessment and attendance.

The basic principles involved are that we have to make productive individuals who can be useful to society, well trained, humane not merely book worms but good at worldly skills as well.

DR.DINESH 1. Student ethics means how they behave during various learning activities i.e. lectures, practicals, clinics etc. It also includes there behavoiur with fellow colleagues, patients. 2. Basic principles of ethics will apply here also. Modern ethics have evolved since the time of Hippocrates, but we still work to assimilate what society considers "right and wrong." Cardinal bioethical principles are autonomy, distributive justice, nonmaleficence, and beneficence. Medical students and residents are taught the phrase primum non nocere "above all, do no harm." The ethical principles of nonmaleficence and beneficence help to define the moral structure for more controversial or complicated issues in modern medicine. It is equally important to promote humanism and kindness by continually emphasizing the need for beneficence in medical practice Dinesh

DR.MONIKA Student ethics means behavior of students with each other in class and out of it, Behavior with teachers in the same situations. Relationships with senior students and juniors-ragging being an important issue.

Ethical principles are involved when medical teachers deal with medical students. I am not aware of a written set of rules and rely on what I think is okay. Medical teachers teach ethics, not just by preaching but also by setting an example to follow. Infact, some of our behaviors in the midst of students can send wrong signals.

Being partial to a particular gender or caste or regional student (and the much discussed faculty kids), ignoring improper behavior in class (thus promoting it) such as talking/chewing/SMS/mobile games/ yawing etc(actually I find these behaviors very distracting and sometimes can break my concentration and actual interest in teaching a class), only focusing on the front benchers and failing to involve the whole group, concentrating on one or a couple of bright students in a clinical batch, being late for a regular class and many more examples of little abnormal behaviors on part of the teacher will actually promote reciprocal erratic and unethical behaviors from the students. For eg. Ignoring misbehaviors will promote more of it, being late for a class will promote students coming at their own willed time, focusing on some will let the others down make them feel on their own and resort to other less useful and improper ways of learning(which includes copying notes) etc.

DR.AROMA !) Student ethics means their attitude to teachers, other fellow colleagues, how they behave in classes, clinics. 2) They should be taught basics &modern principles of ethics

DR.ANSHU From what I have understood, ethics, which involve student- teacher and studentstudent relationships and issues, come under this domain. The issues that I can think of off-hand are: (a) Influencing the teacher through dubious means: All too frequent in India. Where you get messages and phone calls about some student being related to a big-shot/ influential person, and hence requiring preferential treatment in class and exams. Here we are lucky to escape with just requests. But in some places coercion does take ridiculous proportions where students and parents resort to terrorizing teachers. (b) Plagiarism: It is an issue which is taken far too lightly in our Medical Schools. Theses or dissertations are blatant lifts from work of students done in previous years. Guides

are as party to this sin as students are. I think one of the reasons for this is the inability to understand that your thesis need not be a thick 200 page tome. A short and sweet relevant review will suffice. In these days of 'publish or perish', integrity in research needs to be highlighted and sustained. (c) Favoritism demonstrated by the teacher: We have already discussed this issue in detail. However, there is a corollary to this. We tend to make up our minds about how bad a student is from the first impression, and it carries with us till the time he passes out from the college. We need to recognize that a student may not be good in studies, but each student has some positive points. It should be our job to extract and highlight these positives: be it leadership qualities, be it creativity, be it discipline, and be it organizational skills.

(d) Discipline: Enforcing discipline is a tough job, but it need not be a bitter pill prescribed. Practice what you want to preach. If you start your classes on time and end on time, and teach well enough, you will have students attending your classes regularly. I am not sure taking attendance is justified. From my experiences, proxies are commonplace and even if a student is detained for want of attendance, only the less influential are victims of this rule. I feel the attendance in your class is a reflection of how well/badly you teach. I don't know how many of you agree with me on this one.

(e) Respect for the patient: It starts from teaching them to respect the person who willingly donated his body for dissection, so that you could learn. And to respect the patient who one willingly prods, pokes and probes with one's amateur skills so that he/she can become thorough professionals. To teach them not to discriminate a patient on the basis of the strata of society he belongs to or his level of literacy. One skill one needs to consciously teach the students is to talk politely. All too often students see doctors behaving 'superiorly' with patients and tend to emulate the same. In your own domain you might be more knowledgeable, but that does not automatically give you a right to be snobbish. Even if your patient is a mere barber, just try to imagine him

giving you a bad hair cut and you'll know what I mean! We all are dependant on each other, and the sooner we realize that, the better it is for us.

(f) Understanding what it means to be responsible: Our students are at a stage where they are outgrowing adolescence and all too often they exhibit quirky behavior which can best be described as juvenile. But what takes the cake is irresponsible behavior in wards. I have seen interns sending samples so casually that a person, who doesn't have leukemia or malignancy, will get labeled as one, just because of their wrong labels/ samples. 2. Teachers need to be role models and if they exhibit exemplary behavior, the students will certainly follow suit. I guess the same principles that apply to our patients, but exactly how? I am not too sure. My views:

Justice: Treat each student equally and impartially Beneficiance: Let your actions benefit the student (doesn't mean you shower marks!)- but feel free to shower attention and care

Non-maleficiance: Do no harm, do not behave maliciously, do not discriminate Autonomy: Treat your students as adults and expect respect and responsible behaviour to be reciprocated.

DR.CHETNA We are overworked- no doubt about that. In this scenario, how do we teach our students to be more humane and caring? They are going to emulate us, remember? We can include a role-play on communication skills in our teaching modules. Communicating with patients requires patience and empathy and not just knowledge. Its a skill. We had experimented on this in our two teacher training courses and were appreciated. Remember when we "see" in a role play an image of how we behave with patients in the OPD, or with students at the viva table, we begin to introspect and make changes. The same can be extended to students to how they "talk" to patients or examine them.

Sympathy, caring, ethics require not just a mind that thinks but also a heart that feels.

EVALUATE ETHICS EVALUATE ETHICS

DR.CHANDRIKA On par with discussion on how to and what to teach in Ethics, I think it is time to ponder on if we should Asses ethics, be it in students or faculty. If Faculty should serve as role models, it is imperative that faculty know what ethical behavior constitutes and ethics in medical dilemmas which may arise. Assessing ethical knowledge and behavior involves a wide range of tools, some of which are given in the green book we were handed at Ludhiana. Knowledge could be tested as questions and case scenarios. Skills by observation, OSCE, . Attitudes bypatient surveys and standardized patients. In an except from the article: When asked about preferred assessment methods, 20 schools felt variety in assessment tools was important. Only two schools suggested a single method of assessment, both favoring short answer questions. The methods suggested included essays (eight); multiple choice or extended matching questions (seven); an objective structure clinical examination (OSCE) (six); short answer questions (five); a portfolio (five), and a viva (two). Three schools specifically identified different assessment methods for knowledge, skills, and attitudes. When asked about existing assessment methods, two was the norm (range one to five), including essays (10 schools); OSCE or equivalent (nine); multiple choice or extended matching questions (nine); short answer questions (six); written paper (three); portfolio (three); a viva (two), and a presentation (two). All respondents to this question indicated that ethics could be separately identified from integrated assessment formats, although two acknowledged this was difficult. Fifteen schools said it was possible for a student to graduate if they failed their ethics assessment.

Schools said they knew that students were developing the required knowledge, skills, and attitudes in ethics through assessment (20 schools); direct student contact (five), and feedback (two). Additional opportunities to help students assess their own developing knowledge, skills, and attitudes in ethics included feedback (eight schools); formative assessment (three); self assessment (two); seminars (two); reflection (two), and group discussion (two). Small group teaching enables students to get continuous responses to their arguments and ethical positions (Respondent 16).

We are here not to get all we can out of life for ourselves, but to try to

make the lives of other happier. It is not possible for anyone to have better opportunities to live this lesson than you will enjoy. The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. l Sir William Osler.