The History of Medical Ethics in India Looking at the Past as We Try to Change the Future

Abstract

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ABSTRACT

India has had a solid standard for medical ethics since the birth of Ayurvedic holistic science over 5000 years ago. The country’s views on healthcare policy, counsel on how to deal with patients, and what constitutes good behavior within the profession stem from ancient outlines for medical practice. These “codes of conduct” were heavily influenced by religious and spiritual practices, emphasizing the sanctity of life and transcending the needs of the body. With time, however, medical care evolved through shifting priorities in education and governmental pressures. These once-cherished “codes of conduct” were referred to less often, while malpractice issues have steadily increased. There is a need for an open discussion of why this spike in medical malpractice is happening in a country that used to condemn it and how improving ethics, limiting the role of profits, and returning traditional philosophies to the medical ethics curricula could help.

INTRODUCTION

Currently, India has the largest number of bioethics units of any country, reflecting the importance of ethical behavior in Indian society. These centers do not affiliate with schools, yet they serve as spaces for bioethical discourse. The Indian Psychiatric Society (IPS) was the first to address escalating malpractice cases. Other major medical organizations (e.g., the Indian Medical Association and the Medical Council of India) followed, stressing the importance of standardized ethics. Some have formed symposiums and organized conferences to address these concerns.^[1] There have been several calls to revisit the classic “codes of conduct” and their focus on the spiritual concept of life-death-rebirth.

Toward this end, modern Indian doctors were reminded that physicians existed not for fortune or status but for the welfare of their patients. These altruistic teachings came from the seminal Ayurvedic texts, the cornerstone of India’s modern medicine. Happiness for the “healer” was to come out of showing compassion for all living beings and prolonging the precious gift of life.^[2] In contrast, Indian novelist, Shashi Tharoor, speaking on the current state of medical practice, recently remarked: “India is not an underdeveloped country, but a highly developed one in an advanced state of decay.”^[3]

Taking a closer look at what caused the core values of an ancient healthcare system to change so drastically involves evaluating how the Indian medical education system evolved. This paper examines the development of medical principles, their influence across the subcontinent, commercialization, and the government’s role in India’s healthcare instability. This paper then lists some of the measures taken by bioethical units to counteract some of the issues brought on by corruption.

l.     Western Influence

Western influence on medical practices came when the French, Portuguese, and British arrived in India. They almost completely reinvented India’s healthcare system. Medical ethics based on the values of spirituality were almost completely stripped away and replaced by Western concepts.^[4] Established traditional ethical standards were no longer taught, resulting in less deference to traditional moral beliefs. Coupled with an increase in medical misconduct, the general population lost trust in their healthcare leaders.^[5]

Before the influence of Western medicine, the Carakha Sumhita, a millennia-old Sanskrit text detailing Ayurveda, helped establish healthcare guidelines. A passage from the text sums up the ethics of that time: “He who practices medicine out of compassion for all creatures, rather than for gain or for gratification of the senses, surpasses all.”^[6]  The Carakha Sumhita’s focus on medical ethics was ahead of its time, centuries before bioethics became a subject in its own right. Healthcare was predicated on aphorisms that all medical students internalized rather than on business models, as in many developed nations. India’s caste system, established generations ago, permeated every aspect of South Asian society except for when it came to medicine. Healers tended to ignore the conventions of adhering to an individual’s caste. Instead, they treated patients as if they were family and incorporated elements of spirituality when dealing with patients, making ethical misconduct a rare phenomenon. This was the case for almost two centuries.^[7]

To become practicing physicians, doctors committed to a consecration ceremony to prove their good moral standing to the people they were to serve.^[8] Their schooling prepared them for a profession designed to “give back,” not for monetary gain. The core values taught in medical school affect the mentality doctors carry with them.  The lack of ethics training may have been at fault for the underlying corruption levels that now plague the healthcare space in India. 

There is a 110 percent increase in the rise of medical negligence cases in India every year.^[9]  To pinpoint why this occurred, we must look at current medical training practices and how they influence doctors of our time period. After colonization, many established core values were stripped from the medical curriculum.^[10] In fact, by 1998, only one medical college in India, St. John’s in Bangalore, even addressed medical ethics in its curriculum.^[11] Graduates across the country were left ill-equipped to deal with the ethical issues that cropped up once they made it into the field. As a result, they were not prepared to think through consequences pertaining to patients and their families. Some suggest that the curriculum changes were linked to rising malpractice cases.

“When society at large is corrupt and unethical, how can you expect doctors to be honest?”^[12] This topic arises regularly in bioethics discussions and the answer lies in education. Reverting to a system of medicine that encourages students to recognize ethical consequences can solve many of the ethical problems in contemporary society.

ll.     Privatization and Tuition

Some argue that the global increase in capitalism caused the subcontinent’s ethical problems, that the Indian medical education system began its descent into corruption and nepotism, and its loss in prestige, with the privatization of their colleges.^[13] In India, just over 50 percent of medical schools are public, and just under 50 percent are private.^[14] Through changing policies, private medical schools became increasingly for-profit like other businesses.^[15]

Despite having more medical schools than any other country, India has a shortage of doctors, primarily due to low enrollment rates and high university fees. While there are 202 medical schools in India, its large population means there are 5 million people per medical school.^[16] Christian Medical College, a top-ranked university in Vellore, once had an acceptance rate of 0.25 percent, with only 100 seats for medical students.^[17] Now its acceptance rate hovers around 5 percent. There has been minimal progress in making it easier to get a medical school acceptance; there is still a long way to go in equalizing access to education.

India’s system for training doctors is now rife with corruption, with bribes accepted under the guise of “donations” and new curricula completely devoid of traditional Indian training methods.^[18] Nepotism in the industry has made qualifications even less significant. In 2010, 69 hospitals and medical colleges were reported for selling exam papers to students, and most employed staff lied about their clinical experience.^[19] In a cheating scandal in 2013 involving several Indian universities, students purchased falsified entrance exam results. Not only are these students unqualified for the placements they secured, but legal action by the government did not materialize.^[20]

Dr. Anand Rai, a physician who had to go into protective hiding following death threats for being a whistleblower in the 2013 scandal subsequently remarked: “...the next generation of doctors is being taught to cheat and deceive before they even enter the classroom.”^[21] The effects of this scandal can be felt far beyond its borders - India also happens to be the world’s largest exporter of doctors, with about 47,000 currently practicing in the United States.^[22]

lll.     Hospital Privatization

With the privatization of major hospitals and the shift to a “United States” business focus, another serious problem emerged. In the recent past, patients hailing from rural villages and often living in poverty could access quality health care from public hospitals. They had access to highly trained doctors, and all costs were usually fully subsidized.^[23] This was in keeping with the old tradition that believed in aid no matter the circumstance. As the focus shifted towards maximizing profitability, these opportunities for poor patients vanished.

Chains of private hospitals are rapidly replacing public ones. Their purchasing model is to consolidate through a centralized subsidiary.^[24] This usually results in significant savings. Instead of passing on some savings to patients through reduced pricing, any savings are used to fulfill a key objective of privatized businesses: maximize profitability.

The poor now contend with inflated prices and are being turned away from facilities that once treated them at no cost, all while levels of trust in the healthcare system have plummeted. This distrust can discourage people who cannot afford care from seeking medical aid when they need it. The healthcare system has devolved to the point whereby remaining public hospitals are overrun by huge numbers of patients unable to afford the hugely inflated prices at private institutions. This, coupled with healthcare workers that often have substandard training, has created deplorable public health conditions.

lV.     Corruption

This deplorable public health condition reflects a failing healthcare system. To make matters worse, hospitals hire unqualified graduates untrained in medical ethics to meet India's urgent need for large numbers of qualified doctors. Many hospitals have even resorted to employing corrupt doctors to counteract the physician shortage.

According to the Indian Medical Association (IMA), about 45 percent of those who practice medicine in India have no formal training.^[25] IMA also reported that close to 700,000 doctors employed at some of the biggest hospitals, who are currently diagnosing, treating, and operating, have neither the training nor experience to do so. A large-scale forgery ring, broken up in 2011, revealed that buyers could pay as little as 100 US dollars for a medical degree from a non-existent college. This “cleared” them for practice.^[26] It has been estimated that over 50,000 fraudulent medical degrees have been purchased in the past decade.

Government level corruption is widespread, as one can gain placement into medical school, “graduate” with fake degrees, and sell fake practicing licenses.

V.     Solutions

These topics, raised by bioethics centers, are now being taken more seriously by healthcare professionals taking steps to address medical misconduct. As many as five million people in India die each year due to medical negligence.^[27] By requiring each physician to complete a new comprehensive Acute Critical Care Course (ACCC), specialists estimate that physicians can reduce the rate of malpractice deaths by as much as 50 percent in rural areas.^[28] This intensive two-year course contains detailed training methods built off of current knowledge and walks healthcare professionals through crucial steps designed to reduce errors. Even small errors, such as a poorly inserted IV for fluid or a minor surgery mishap, can be life threatening. The course thoroughly covers these as mandated.^[29]  The ACCC is unfortunately not a widely spread concept in a lot of rural areas. For now, while many major hospitals continue to ignore the high rates of avoidable deaths, implementation of the ACCC program seems slow.

The current Medical Council of India needs to be more effective at addressing malpractice cases, as there are so many of them.^[30] One possible solution to the growth of unethical business practices in medicine is to offer physicians incentives to make ethically sound decisions. This can start by increasing the number of slots available for medical students at government-run medical schools. Less student debt would lead more doctors away from overbilling their patients. This is a strategy currently being employed in the state of Tamil Nadu, where a centrally sponsored scheme has approved the induction of an additional 3,496 MBBS seats in government colleges.^[31] More students studying at subsidized costs with less competition lowers the inclination toward deceit and profiteering.

Another incentive for ethical practice can come from accountability and transparency. The background of every doctor operating should be public information, including the rate of successful surgeries versus unsuccessful ones resulting from personal negligence. This would encourage doctors to keep a clean record and, in turn, encourage hospitals to hire and train those who will preserve or improve their reputation. This information is kept in a medical record monitored in most parts of India through a traditional paper method.^[32] While eliminating paper in medical recording and reverting to digital use is the ultimate aim, it will take time to implement a system that takes into account e-signatures and verifiable witnesses.

CONCLUSION

India’s history of leadership in medical ethics has undergone some major changes. A relatively recent privatization of the education system has caused a shift in values and decimated the medical industry on many levels. The moral principles of doctors have come into question. While industry and government leaders are trying to solve the multi-faceted issues facing the medical industry, it is obvious that this is an undertaking requiring inventive solutions.

Prioritizing ethics in medical education, de-privatizing medical schools and hospitals, offering affordable options, and limiting corruption would improve India’s ability to offer high-quality medical care. Adding traditional Indian medical ethics back into the curricula would foster a workforce dedicated to serving patients over profiteering.

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^[1] Deshpande, SmitaN. 2016. “The UNESCO Movement for Bioethics in Medical Education and the Indian Scenario.” Indian Journal of Psychiatry 58 (4): 359. https://doi.org/10.4103/0019-5545.196722.

^[2] Mukherjee, Ambarish, Mousumi Banerjee, Vivekananda Mandal, Amritesh C. Shukla, and Subhash C. Mandal. 2014. “Modernization of Ayurveda: A Brief Overview of Indian Initiatives.” Natural Product Communications 9 (2): 1934578X1400900. https://doi.org/10.1177/1934578x1400900239.

^[3] 2020. Eubios.info. 2020. https://www.eubios.info/EJ102/EJ102E.htm.

^[4] Arnold, David, ed. 2000. “Western Medicine in an Indian Environment.” Cambridge University Press. Cambridge: Cambridge University Press. 2000. https://www.cambridge.org/core/books/abs/science-technology-and-medicine-in-colonial-india/western-medicine-in-an-indian-environment/28BAB761BE205B06D32BC3DC972E9384.

^[5] Kulkarni, Vani, Veena Kulkarni, and Raghav Gaiha. 2019. “Trust in Hospitals-Evidence from India.” https://repository.upenn.edu/cgi/viewcontent.cgi?article=1026&context=psc_publications.

^[6] Bhasin, Dr Sanjay K. 2005 “What Ails Medical Profession.” Www.academia.edu. Accessed September 17, 2022. https://www.academia.edu/7631547/What_Ails_Medical_Profession.

^[7] Shapiro, Natasha, and Urmila Patel. (2006) “Asian Indian Culture: Influences and Implications for Health Care.” https://www.molinahealthcare.com/~/media/Molina/PublicWebsite/PDF/providers/fl/medicaid/resource_fl_asianindianculture_influencesandimplicationsforhealthcare.pdf.

^[8] Swihart, Diana L, and Romaine L Martin. 2021. “Cultural Religious Competence in Clinical Practice.” Nih.gov. StatPearls Publishing. 2021. https://www.ncbi.nlm.nih.gov/books/NBK493216/.

[9] “India’s Mighty Medical Education Mess.” 2022. Education World. July 11, 2022. https://www.educationworld.in/indias-mighty-medical-education-mess/.

^[10] Pandya, Sunil. 2020. “Medical Education in India: Past, Present, and Future Perspectives. in Sun Kim, ed. Medical Schools Nova Science Publishers, Inc. (=

^[11] Ravindran, G. D., T. Kalam, S. Lewin, and P. Pais. 1997. “Teaching Medical Ethics in a Medical College in India.” The National Medical Journal of India 10 (6): 288–89. https://pubmed.ncbi.nlm.nih.gov/9481103/.

^[12] “Chapter 9: Opinions on Professional Self-Regulation”(2016) https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/code-of-medical-ethics-chapter-9.pdf.

^[13]Sanjiv Das. 2020. “The Pill for India’s Ailing Medical Education System.” Express Healthcare. February 3, 2020. https://www.expresshealthcare.in/education/the-pill-for-indias-ailing-medical-education-system/416711/.

^[14] https://www.marketresearch.com/Netscribes-India-Pvt-Ltd-v3676/Private-Medical-Colleges-India-30399614/."There are ~50.89% government medical colleges and ~49.11% private medical colleges in the country.”; NPR.org. (2021) “When Students in India Can’t Earn College Admission on Merit, They Buy Their Way In.” Accessed September 19, 2022. https://www.npr.org/2019/08/04/745182272/when-students-in-india-cant-earn-college-admission-on-merit-they-buy-their-way-i. 

^[15] https://timesofindia.indiatimes.com/india/how-medical-colleges-in-india-became-a-business-one-policy-change-at-a-time/articleshow/69707594.cms

^[16] Muula A. S. (2006). Every country or state needs two medical schools. Croatian medical journal, 47(4), 669–672. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080437/

^[17] Miglani, Andrew MacAskill, Steve Stecklow, Sanjeev. 2015. “Why India’s Medical Schools Are Plagued with Fraud.” Mint. June 17, 2015. https://www.livemint.com/Politics/BDGOx3SApU3QbsRMjZUK9M/Why-Indias-medical-schools-are-plagued-with-fraud.html.

^[18] Clark, J. 2015. “Indian Medical Education System Is Broken, Reuters Investigation Finds.” BMJ 350 (jun18 3): h3324–24. https://doi.org/10.1136/bmj.h3324. 

^[19] Reuters. 2015. “Special Report - Why India’s Medical Schools Are Plagued with Fraud,” June 16, 2015, sec. Special Reports. https://www.reuters.com/article/uk-india-medicine-education-specialrepor/special-report-why-indias-medical-schools-are-plagued-with-fraud-idINKBN0OW1N520150616.

^[20] Andrew Emett. (2015) “Over Two Dozen Witnesses and Suspects Mysteriously Die in Indian Cheating Scandal | NationofChange.” Accessed September 19, 2022. https://www.nationofchange.org/2015/07/08/over-two-dozen-witnesses-and-suspects-mysteriously-die-in-indian-cheating-scandal/.

^[21] (Reuters 2015)

^[22] Clark, J. 2015. “Indian Medical Education System Is Broken, Reuters Investigation Finds.” BMJ 350 (jun18 3): h3324–24. https://doi.org/10.1136/bmj.h3324.

^[23] Barik, Debasis, and Amit Thorat. 2015. “Issues of Unequal Access to Public Health in India.” Frontiers in Public Health 3 (October). https://doi.org/10.3389/fpubh.2015.00245.

^[24] “Investment Opportunities in India’s Healthcare Sector.” (2021) https://www.niti.gov.in/sites/default/files/2021-03/InvestmentOpportunities_HealthcareSector_0.pdf.

^[25] Clark, J. 2015. “Indian Medical Education System Is Broken, Reuters Investigation Finds.” BMJ 350 (jun18 3): h3324–24. https://doi.org/10.1136/bmj.h3324.

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^[28] “Specialised Course for Doctors Can Help Cut the Deaths due to Medical Errors; Experts.” 2018. DailyRounds. October 29, 2018. https://www.dailyrounds.org/blog/specialised-course-for-doctors-can-help-cut-the-deaths-due-to-medical-errors-experts/.

^[29] Sokhal, Navdeep, Akshay Kumar, Richa Aggarwal, Keshav Goyal, Kapil Dev Soni, Rakesh Garg, Ashok Deorari, and Ajay Sharma. 2021. “Acute Critical Care Course for Interns to Develop Competence.” The National Medical Journal of India 34 (3): 167–70. https://doi.org/10.25259/NMJI_103_19.

^[30] Singhania, Meghna A. 2020. “How Much Punishment?- MCI Formulates Sentencing Guidelines for Cases of Medical Negligence.” Medicaldialogues.in. February 13, 2020. https://medicaldialogues.in/news/health/mci/how-much-punishment-mci-formulates-sentencing-guidelines-for-cases-of-medical-negligence-62645.

^[31] “Health Ministry Reports 30% Increase in Number of Functional Medical Colleges in Five Years.” (2022) Www.pharmabiz.com. Accessed September 19, 2022. http://www.pharmabiz.com/NewsDetails.aspx?aid=152299&sid=1.

^[32] Honavar, Santosh G. 2020. “Electronic Medical Records – the Good, the Bad and the Ugly.” Indian Journal of Ophthalmology 68 (3): 417. https://doi.org/10.4103/ijo.ijo_278_20.