‘What ails the practice of medicine: The Atlas has shrugged’ is indeed a provocatively titled enquiry by Dr. Sundeep Mishra, which etymologically derives from the magnum opus by Ayn Rand – ‘Atlas Shrugged’. In one of the philosophical conversations in the novel, d'Anconia asked Rearden for his reaction on the plight of the mythological Titan, Atlas – ‘The greater his effort, the heavier the world bore down upon his shoulders’! With no response forthcoming from Rearden, d'Anconia responded himself with the advise for Atlas – ‘To Shrug’.
Sundeep Mishra tries to draw a simile between a dystopian society portrayed in the novel and an equally dystopian modern medicine – a profession held on a Pedestal of Godliness, quite akin to Atlas's shoulders, since antiquity.
But alas, the Atlas of Medicine is long dead and ‘Dead’ don't ‘Shrug’! A probable reclaim is in a Vedantin's mindset that only the physical body of ‘Medicine’ has decomposed, the soul is intact and that we can resurrect. True or not, sure does give some hope and motive power.
1. When, where and why did this rot start?
Dr. Mishra dwells into the various factors that are responsible for the deterioration of morality in medical practice. Well before we debate on this aspect, lets first look at what is medical ethics? Medical ethics deals with moral decisions in various aspects of medicine. The ‘Hippocratic oath’ is the most enduring tradition in medicine that has been the guiding ethical code for physicians since ancient Greece and has eventually become the basis of all medical ethics. Essentially it emphasizes the profundity of the medical agreement, the patient dignity, the right to confidentiality and the physicians responsibility to guard against abuse or corruption of his or her knowledge and art. It also exhorts the physicians to honour the rules of the profession & treat other medical practitioners as brethren and yet expose those who do not follow the high standards of conduct. At this point, I think it is necessary to clear a general misconception that practice of medicine and ethics are two independent and divergent subjects or that ethics is merely an adjunct to medical activity. There can be nothing further from truth than this presumption. To the very contrary, the two are irrevocably harnessed together and this marriage has been recognised since before the days of Charak, Sushruta and Hippocrates.
However lately the medical profession in India, and probably the world over, is in crisis with an unrelenting downward spiral of deteriorating ethical and moral aptitudes. The “dollar” is now the adored deity and the profession has been both privatised and commercialised. Our senses have been vitiated to the extent that they see qualification & pleasure only in materialistic returns & not in love, blessings or grateful thanks from the bottom of heart of a suffering soul. This has also produced a highly selfish mentality with resultant exploitation of the patients more so in the absence of any guiding ethics.
Our medical curriculum, though extensive as far as the equivalent of the three ‘Rs’ is concerned, do not lay adequate stress on teaching of ethical goals and the need for development of interpersonal relationships between a doctor and his or her patient. Ethical issues may be touched upon in passing, but ethical dilemmas are rarely the subject of detailed ratiocination.
Infact, one of the levels of the Hippocratic oath states that it is a physician's duty to teach his students all he knows, freely & without thought of remuneration. The professionally sound & ethically upright teacher is in the best position to appear as a role model for his impressionable pupil. The ideal is some times very far from reality. Full time teachers are often disenchanted & uninterested and the under remuneration does nothing to improve their psyche & they churn out equally dull & incompetent ‘capitation’ doctors, with limited intellect, none feelings and passion, and given to bacclanalism of the pugnacious squirearchy.
Equally disturbing is the new tendency of riding rough shod on our colleagues and making gains from their misfortunes. A patient who develops a grouse against a doctor based on some real or imagined mistake can be extremely disparaging and indiscrete in manner of speech. A patient is in a diseased frame of mind. He approaches a doctor with feelings of faith and hope. Yet there is an underlying current of fear, hostility and distrust. With such mixed feelings there is every likelihood of misunderstanding and exploitation by either involved. We some times tacitly approve of this behaviour of the patient. To criticise a colleague in front of a patient is both damning & dangerous and can never be justified. The basis of a good relationship amongst doctors lies in mutual respect and understanding, for a feeling of loyal commarderie is essential not only for the sake of our profession, but also for the welfare of the patients.
2. What then needs done?
I grant the author's views on morality of rational self interest but disagree on regulation. Infact failure of governmental coercion was adequately demonstrated in ‘Atlas Shrugged’, which incidentally is not just fiction but infact a school of philosophy developed by Ayn Rand, after practical study of operations of industrial units like Kaiser Steel Plant and New York Central Railroad.
Schopenhauer once said, ‘Man can do what he wants but can't want what he wants' demonstrating thereby the might of ‘Thought’ over ‘Action’ – infact a Vedantist's view too. Regulation can target the latter but the thoughts can only be sanitized through ethical imbibings gained experientially at individual and societal levels. The proverbial fatty streaks of ethical dilemmas get sowed in utero and need nipping in the bud.
We all look for scape goats, not realizing that we are collectively responsible – ‘Good’ more than the ‘Bad’. The current plight of medicine is portrayed as one due to the rotten few in the profession, but trust me, the so called ‘Good’ and the ‘Honest’ people are responsible in an equal measure, if not more, because they sat on their butts and did nothing when the contumacious knaves were running askew – a s'il vous plait attitude.
Despite all the awareness and negative press, the majority group of honest doctors tend not to bother about the corruption in medical practice and their quietness is thus construed as connivance or complicity. This I think is a grave error. John Galt philosophises in ‘Atlas Shrugged’, ‘Evil is impotent and has no power but that we let it extort from us … …. The only weapon of its triumph is the willingness of the good to serve it’. It is for us to insist from our brethren the highest ethical standards and not leave it upon society, politicians or judiciary to set us on the right path. The modern individualistic attitude and total lack of concern for the need of a value system in life does not auger well for the future medical scene in India in particular, and the world at large. The declining moral trends indicate an unhealthy inter-human relationship and, I repeat, any appeal for political intervention or seeking help from the Judiciary or trying to rectify the situation through medical associations and councils shall prove to be of no avail. Infact, regulatory bodies have time and again proved to be worse than useless and shall continue to do so for perpetuity unless we overhaul the doctrinal ‘Pede poena clauda’.
Swami Vivekanand once said, “Access of knowledge and power without holiness makes human beings devils”. Let me add to it, money. The triumvirate of Money, Power & Knowledge make a heady mix, and if unbridled, can but only spell doom for this noble profession. Bridled it can be, but only if the reductionist medicine of Descartes yields to, or at least pairs with, the holistic, traditionally eastern system of medicine, wherein science and spirituality have common meeting grounds. Infact spirituality has been included in the didacted schedule of medical teaching in United States of America in most medical schools, whereas unfortunately in the country of its origin, it is yet to come to fruition. Unless we break the vicious cycle of the triad, it will be very difficult for us to ever regain the glory that our superiors and seniors had in the bygone era, when doctors were given a Godly pedestal – a Titanic Atlas, that today is dead and defunct or nearly so, and sooner rather than later may come crashing down and ruined for ever.
And that is the least of what we owe to the gen next of our fraternity – revive and resuscitate the pedestal, if not exalt it!
3. But here comes the moot question – who is going to bell the cat?
‘What pains is not the words of enemies but the silence of loved ones’
Many doctors feel that the profession is going from bad to worse and they no longer share a sense of pride in being a doctor, a kind of bitter swill of the swallowed back anger and frustration, but they do not speak out. “The world is a dangerous place, not because of those who do evil, but because of those, who do nothing”, said Albert Einstein. Just being honest is not good enough – a case in point is our Ex Prime Minister, Manmohan Singh. He personified what Edmond Burke had quipped eons back, “For evil to flourish, all that is needed is for good people to do nothing”.
We will therefore have to tame our own selves and it is for the wise and the sane, the seniors amongst us to take the lead. They have to make a choice – behave like a visionary Utopian or a Quixotic naïf. Not only they need to speak out but also like a beacon light the way and mentor the junior colleagues – a facet of medicine which seems to have been consigned to the archives. No wonder then, it is often sardonically said, “There are 3 Ms on which medical profession in general is woefully weak – Manners, Morals & Medicine”. Mentoring therefore has to be not only for the science, but also the art & ethics, of practice of medicine. As stated by Dr. F. Udwadia, “Good teaching, though concentrating on essentials, must question dogma, must arouse & encourage an attitude of inquiry and a thirst for knowledge & serve as a stimulus for further study. Above all teaching must be imbued with an ethical start”. As for our junior brethren, if they aspire to retrieve the tilting pedestal, they need to revisit their graduation day and have another close and honest look at the oath they took, when they so proudly assumed the prefix ‘Doctor’! And Act!
Conflicts of interest
The author has none to declare.