Published by the government of Zimbabwe
28 June 2008
opinion
Harare — I would like to take this opportunity to write about ethics in medical care, because it has become an issue all over the world.
This is the result of the progress in societal development, and, in particular, the exponential growth of access to information, which we have all experienced in the last decade. I believe in the principle, encapsulated by the American Medical Association in Chicago in 1969, that public or private health has the duty to render service to humanity with dignity in mind.
"(Physicians) should merit the confidence of patients entrusted in their care, rendering to each a full measure of service and devotion to their [medical and social] needs." We cannot expect any third party, whether it be medical aids or government to monitor our every action. Of course, with the emergence in medicine, as elsewhere, the State has a responsibility to protect patients from charlatans and serial murderers, like Oswango and Shipman, but the profession of health care cannot be codified as are rates or taxes.
The health worker, of whatever discipline, has not merely to save life and treat illness, but also to be someone to whom the patient can confide, and expect those confidences to be respected. The patient also expects to be treated decently - like a human being - and be brought into the confidences of his diagnosis and treatment, as well as being protected from degrading or disgraceful conduct. Too often in a busy day's schedule the pursuit of greater knowledge and expertise takes precedence over the patient's comfort. I suggest that even the discussion of the fee to be raised, and how, and when, it should be paid forms part of the patient's dignity. Too often this is done in public, by people, employed by the doctor, who have no concept of the difference between loaves of bread and the patient's confidential diagnosis.
This, however, is not to deny the need for health practitioners "striving continually to improve medical knowledge and skill". As long ago as 1857, Vidal bemoaned the fact that "the cleverest of venereologists, who could be of the greatest service to science regard experimentation as immoral." This echoes Winston Churchill's alleged comment, when penicillin was found to be effective in curing the common venereal diseases, gonorrhoea and syphilis - Does it hurt?
He was, of course, referring to the treatment, with the implication that if the patient suffered, the treatment could be authorised! In the rush to improve medical science the interests of the subject, or patient should always be paramount. I used to complain, publicly, that as Minister of Health I only got to know that some research had been carried out, in Zimbabwe on Zimbabweans, when I read the final, published report in some scientific journal, usually from the UK or America.
Lately, such surveys or "research" has been appearing even in the popular press. The participants (or victims) were never told of the research, or never benefited or were even aware that research was being carried out. Still less, were they notified of the results of that "research" and how it could benefit, in the long term, either themselves or humanity in general. That is despite clear guidelines being laid down, in this country, as to how medical research should be carried out, and legislation (the Public Health Act) requiring the approval of the Secretary for Health before research is started. This reminds me of a story about a young healthy blonde who came to the doctor and asked him why he changed the tablets on the second visit. The doctor said, "Why do you ask?" "Oh", said the blonde, "when I sent the first lot down the toilet they sank, this lot floated!" So much for random double blind trials.
When I was in the learning curve of Commercial Private Medicine, in Rhodesia, Kipps Rosin, who was a very highly esteemed surgeon, turning to me in the changing room and saying to me with a wicked smile on his face, "do you know why I had to take out this perfectly normal appendix tonight at 10pm?", "No", "Because, if I did not take it out, then Dicky Langford would do it in the morning."
I was surprised to find the mother of the patient very happy and grateful that there was nothing wrong with the appendix. Arbuthnot Lane, who was so appalled with the contents of the large bowel, which he had removed previously from infected patients, that towards the end of his illustrious career he used to take out the large bowel routinely when he opened the abdomen for any other purpose, leaving the patient with a continuously operating colostomy (a bag attached to the front of the abdomen which fills the waste products and has to be changed frequently) on the anterior surface of the abdomen. In my first job, in Cardiff, as a surgical assistant, I had the privilege of meeting a former Rear Vice Admiral, who was at that time Professor of surgery at Medical School recalling Arbuthnot Lane trying to stop a bleeding artery by putting a pair of forceps around the spurting blood, commenting how the blood would not stop, no matter how hard he compressed the blood stream!
There comes a time in the life of a Medical Practitioner, where he is more of a danger to the patient than a benefit, and I suppose this can be extrapolated to other health professions. However, this does not preclude mistakes being made by a perfectly sane health worker and my father used to tell me, Show me a man who never made a mistake and I will show you someone who never did anything useful. In fact the fear of courts or the regulatory bodies makes us less likely, not more likely to admit our mistakes. One mistake I made myself was to treat a patient with pre-tibial oedema (kuzvimba). When he got slower and weaker I thought he was suffering from potassium (K) deficiency, so I added "slow K" to his diuretic regime.
He had always been slow. His command of English was not very extensive, but another colleague hit upon the correct diagnosis and kindly informed me that a tablet of eltroxin (thyroid hormone) was the appropriate treatment and the patient got rapidly better under his care.
We are all human. The issue is, let us be objective about diagnosing and treating our patients and ensuring that they get correct, effective, available and the cheapest form of treatment, so that they can get better. After all that is the sole objective of being a health worker, otherwise we should not encumber the earth.
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