Low Ethical Standards Are Common in Medical Education in India

Prevention of patients from exploitation and protecting their human rights is the aim of modern medical ethics but the objectionable attitude of Indian doctors towards informed consent is a worrying trend.

• It’s not very long when the doctors and researchers of the country were trying to grapple with the SARS-CoV-2 variant, and douse the flames of Covid-19.
• That was the time when the issue of informed consent by the marginalised participants in the clinical phase-3 trial of the Covaxin got emerged.
• And this is not a standalone case of unethical medical practice, there are many others.

It makes sense, to begin with, the Hippocratic Oath, that most doctors pledge to adhere in his or her practice. It was developed by the Greek physician Hippocrates some 2,500 years ago, shaping the principles of medical ethics. It demonstrates the ethical principles of beneficence, non-maleficence and confidentiality. Despite this, there are reasonable practical implications where clear divergence forms the minutes of the oath cannot be ignored.

Instances of ethical divergence:

• Medical students introducing themselves as doctors: In a survey at the BPS Medical College, Bhopal, it was found that 20 percent of the medical students believed that patients need not to know about the qualification of their doctors. And as the same time, it is common for medical students to introduce themselves as a doctor while interacting with the patients. This stance has its own ethical and legal implications.
• Clinical Implication: The possibility that the mentioned doctor may not be knowing the answers to every question of their patient cannot be ruled out. This makes the patient mistrustful about the hospital as well as the prescribed treatment because the patient can perceive that the doctor does not know enough about his ailment.
• Legal Implications: A medical student in the eyes of law is not qualified to provide treatment or to suggest intervention but still they might do so in order to escape from being embarrassed in front of their patients.

• Patients being evaluated by a parade of medical students: In many Indian hospitals it’s common to evaluate patients by a parade of medical students, and each one claims to be a doctor. The outcomes are many.
• Feeling of Mistrust: Although the whole exercise, solely meant to evaluate the patients for the purpose of learning but they are either unaware of it or has not been asked for consent may reason that the doctors were not able to diagnose the ailment and compel him to consult another doctor.
• Feeling of Humiliation: The patient who is either recuperating or struggling with the aliment often gets the feeling of him getting subjected to humiliation, where he is being treated as a “doctors’ toy”.

• Induction of marginalised people for phase 3 trial of Covaxin: In Bhopal marginalised and illiterate people were inducted in phase 3 clinical trial of Covaxin without their consent and with promises of money.

The core reason behind this problem: It is the consent

• Medical practice these days cannot be seen in the absence of various factors influencing the doctor-patient relationship. The concept of consent is the foundation stone of the relation that a medical practitioner and the patient mutually share with each other.
• The patient has a legal right to autonomy and self-determination enshrined within Article 21 of the Indian Constitution. He can refuse treatment except in an emergency situation where the doctor need not get consent for treatment.
• The concept of consent comes into existence from the principle of patient autonomy and basic human rights.

Types of Consent in the field of medicine:

• Implied consent: The moment a patient enters the doctor’s room and expresses its problem is considered as an implied or implicit consent for the purpose of treatment or routine examination.
• Expressed consent: On the contrary invasive tests, intimate examination and procedures involving risks require a specific expressed consent. It is generally given in writing to the doctor.
• Informed consent: It is a process where the participants or the patients are informed about the trial (clinical), which is important for the participants to make a decision that voluntarily confirms his or her consent to participate in a trial. This amount to truthfully providing accurate, adequate and relevant information in simple language that the patient can understand.

The problem in India:

• Objectionable attitudes: Despite being trained to understand the importance, the doctors continue to show objectionable attitudes the informed consent. There is a need for doctors to change their attitude and acknowledge the patient’s autonomy. It's not easy to know the truth as the trial researchers simply state that, they do have informed consent.
• Dysfunctional system: In general, the Indian medical ecosystem disregards patients’ rights. This argument can be supported by sighting a survey of doctors in North India, in 2013. It was concluded that 90 percent of doctors believe that the health status of patients necessarily is disclosed to their close relatives irrespective of consent.

Possible solution:

• National Medical Commission (NMC) new MBBS curriculum includes ‘attitudes, ethics and communication’. It aims at producing doctors who practise ethical medicine.
• The doctors need to explore the practical implications of unethical medicine in a clinical setting as making them to study the theories involved will only do justice to studies ahead of the exam and not more than that.
• The doctors in government hospitals need to pay attention to patient privacy and avoid consulting more than one patient at a time.
• Doctors should refrain from disclosing their patient’s personal information like their names, place of residence, educational level and profession while doing intramural case presentations or discussing the case with peers or colleagues.
• The government of India is also planning to launch a National eHealth Authority which will work towards enforcing the standards to ensure security, confidentiality and privacy of patient’s health information and records.
• A significant part of the Indian population is marginalised & vulnerable, so a proper framework and protocol that is biding to the doctors are essential, particularly in public sectors hospitals that cater to the people particularly living on the fringes of society.
• The security of the personal data of the patient must be secured through the use of administrative and technological control. The Health data management policy of the National Digital Health Mission (NDHM) sets the minimum standard for data privacy protection. It has the potential to improve the transparency and effectiveness of health services in India.

Conclusion:

Consent is a lawful right of a patient that makes a decision their involvement in clinical procedures. The knowledge and approach of consent are foremost important for the general population as well as to the medical field practitioners. Thus, it is impossible to expect a change without increasing the awareness among patients about their rights and alongside placing stronger laws that can ensure that the doctors or the health care providers do the right thing.