A Paper Code ( From the Editorial of EPW, May 18-2002)

Undoubtedly, the moribund systems for regulating medical practice in India are undergoing a shake-up. The question is how critically this will impinge on the availability of good health care for all. Will the pieces fall into a manageable pattern, which allows for enforcing a strict code of conduct while leaving sufficient room for a patient-doctor relationship that transcends the realms of the marketplace? It may justifiably be argued that in an environment that has seen wide-ranging and gross violations of medical ethics, it would be irrelevant to talk of pristine relationships or of transactions other than those of the marketplace. However, the new code of medical ethics, the ‘Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002’, is so farsighted as to prompt a flight into the realms of utopia. After all, where else can a physician be called upon as “an upright man” to “keep himself pure in character and be diligent in caring for the sick…be modest, sober, patient, prompt in discharging his duty without anxiety, conducting himself with propriety in his profession and in all the actions of his life”?

There is much that is right with the new code, the first major change since 1956 when the Medical Council Act was first revised in independent India. It defines duties and obligations on the part of the physician and to some extent codifies many generally-held assumptions of correct and ethical behaviour including issues of confidentiality and the professional’s role in mercy-killing. It prohibits in clear terms a doctor’s involvement in torture. It delineates when consultations should be resorted to keeping in mind at all times that “the benefit to the patient is of foremost importance” and forbids the doctor’s involvement in euthanasia and in conducting sex determination tests.

Most important are the prescriptions on fees and payments and record-keeping. The new code stipulates that the physician display his “fees and other charges in the board of their chamber and/or the hospitals he is visiting”. Further, prescriptions are required to include information on whether the medicines have been dispensed in-house. It is unethical, says the code, to enter into a “no cure no payment” contract. Physicians rendering “service on behalf of the state” are expected to refrain from “anticipating or accepting any consideration”. But how is all this to be enforced in an environment where medicare is at a premium and ‘patient power’ only a notion? A physician is now required to keep full records on indoor patients for a period of three years and is required to produce it on demand within 72 hours. Given that most independent practitioners rarely keep any kind of records at all, this is an ambitious objective.

The code makes it mandatory for the practitioner to undergo some training as part of continuing medical education programmes for “at least 30 hours every five years” and compliance with this requirement is required to be regularly communicated to the MCI or the state councils as the case may be. However, unless this requirement is tied to the renewal of registration and the MCI devises some way of evaluating the level of skill/knowledge upgradation, this is a meaningless rule. Skill upgradation is an important issue because often mis-treatment can emanate from a practitioner who has not kept abreast of current practice. While the code stipulates that misconduct will be duly investigated and those guilty punished, the onus of bringing misconduct to the notice of the council is with patient or the public on behalf of the patient or a physician colleague. The new code has no associated order that sets up monitoring mechanisms. There is no indication that the MCI intends to ensure that the code is followed. Unless there is a concerted people’s initiative at the local level, who is to monitor whether medical practitioners, for example, display their fees and charges or have not accepted ‘cuts’ for referrals or are even keeping records?

The current conduct of the MCI in regulating medical practice or medical education – tasks with which it has been charged under the Medical Council Act 1956 – provides little confidence in its ability to undertake the additional task of implementing the new code. For some time now the manner in which its functionaries are elected has come under severe scrutiny, exposing gross lack of ethics in the conduct of the elections. State MCIs have become fiefdoms controlled by a few individuals who distribute largesse, protecting wrongdoers and violating norms and regulations on admission to medical colleges, setting up of new colleges and other aspects of medical training and practice. The recent case of Ketan Desai who headed the MCI as well as the Indian Medical Association (IMA) and was found guilty of corruption and abuse of power by the Delhi High Court and summarily ordered to be removed from his post in the MCI is not so much an exception even if it may not be quite the rule. On a complaint from another doctor, Desai has been accused of amassing a small fortune for providing a variety of services – over medical admissions, interfering with routine MCI inspections of medical colleges, etc. Some years ago in Maharashtra, large-scale and routine rigging of elections to various offices in the Council had come to light. More often than not, issues that ought to have been decided by the MCI have ended up in courts because of the Council’s inability to adjudicate.

The lack of discipline and order in the functioning of the Council is an issue closely linked with the fact that the MCI has little authority to undertake mandated tasks. For example, although no new medical colleges can be set up without the approval of the MCI, every state routinely allows such institutions to be established regardless of whether MCI-stipulated preconditions have been fulfilled. While the MCI may withhold approval for a year or two, pressure is brought on it – through court cases by students already admitted or from political sources or other means – to reverse its decision. Repeated dilution of rules ensures that monitoring mechanisms are not taken seriously in any quarter. There have been attempts to review the MCI Act so as to give the institution more teeth, but their progress has been painfully slow on account of political and administrative stumbling blocks.

The present code is the outcome of the sustained work of small bands of professionals across the country who, at the risk of professional ostracism, have joined issue with the MCI over its corrupt practices and its inaction on rampant unethical practices. Unfortunately, there is a real danger that the passage of a code that appears to be progressive may become an end in itself. Ensuring a better regulated, ethical and patient-friendly medical practice can become a reality only in the context of greater access to health care and a revitalisation of the sector. But given the manner in which the extensive responses to the draft health policy have been swept aside, there is little evidence of any such resurgence.