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Low Ethical Standards Are Common in Medical Education in India

Low Ethical Standards Are Common in Medical Education in India

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  • It is fairly common for medical students to introduce themselves as ‘doctors’ to patients, but doing so can increase quality-of-care expectations.
  • Many doctors as well as patients in India have a lackadaisical attitude towards patient confidentiality.
  • The attitude problem also extends to medical research, observational studies, in which it is common to ignore the need for patient consent.

“This doctor saab will see you,” my mentor told a patient in the out-patient department as he pointed to me. As a medical student, I felt elated on being called a ‘doctor’, but this was followed by a sense of unease as the patient looked at me with expectant eyes. Now, I was supposed to stand up to the patient’s expectations of a doctor.

In India, it is fairly common for medical students to introduce themselves ‘doctors’ when interacting with patients. While teaching a procedure, even resident doctors and faculty members often address medical students as ‘doctors’, to develop credibility in the patients’ eyes. However, a survey at the BPS Medical College, Bhopal, found that one-fifth of the medical students surveyed believed patients don’t need to know their doctors’ qualifications.

This stance has some ethical and legal implications. In a clinical interview, patients often ask about the nature of their ailment, their treatment course and expected outcomes. Medical students may not know the answers to all these questions – which a patient may interpret as “my doctor does not know enough about my ailment”, and become mistrustful of the hospital as well as the prescribed treatment. Second, medical students are not legally qualified to provide treatment options or suggest interventions – but they might do so to escape being embarrassed in front of their patients, who see them as doctors.

Starting one’s medical career by lying to patients doesn’t set a good ethical foundation, and students could form a habit of betraying patients for self-interest. In some hospital wards, patients are evaluated more than once, and often multiple times, by a parade of medical students, and each one claims to be a doctor. But while these students are meant to evaluate patients solely to learn, the patients may reason that their doctors are not able to make sense of their disease, and compel them to consult with another doctor.

In one instance (that I witnessed first-hand), a patient’s wife demanded that her husband, who had been evaluated by multiple students, be discharged asap because he was being treated like a “doctors’ toy”.

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Although the National Medical Commission (NMC) included ethics and communication training modules to the MBBS curriculum in  2019, a lack of good role models has become a major problem in medical colleges. Many doctors in government hospitals pay little heed to patient privacy and often consult more than one patient at a time.

During intramural case presentations – when doctors discuss case details with their peers or colleagues in the same facility – it’s the norm to include patients’ personal details to an unnecessary degree, including name, place of residence, income, education level and profession. When doctors seek their colleagues’ opinions, they exchange documents containing patient information over WhatsApp or email without redacting sensitive personal information. Many doctors often disclose their patients’ health information to their family members without getting the patient’s consent first.

In one alarming survey of doctors in North India, in 2013, nearly 90% said they believed the patient’s health status ought to be disclosed to their close relatives irrespective of consent.

A part of the problem is the paucity of laws related specifically to patient privacy and confidentiality in India. Compounding this, most patients also have a callous attitude towards the confidentiality of their medical records. One 2012 study found that only 27% of its (healthcare-seeking) participants believed their health and medical history to be their personal property and not amenable to being shared freely. This is in stark contrast to attitudes in the US, where disclosing even remotely identifiable information is understood to be a violation under the famous Health Insurance Portability and Accountability Act (HIPAA).

Having a medical code of ethics is even more relevant in the context of medical research. In any study that involves human participants, the study administrators – led by the principal investigator – have to seek and receive each participant’s informed consent before the study can begin. This procedure requires investigators to discuss all information about the study with potential participants, make sure they have understood all the details, ensure they sign off in writing, and finally share a copy of the agreement with the participants. The concept of informed consent took shape in the 1970s after several heinous unethical medical experiments came to light, including, notably, the infamous Tuskegee syphilis study.

The modern code of medical ethics aims to prevent healthcare workers and researchers from exploiting patients and protecting their human rights in the context of care-giving. But multiple studies have reported that Indian doctors continue to harbour objectionable attitudes towards informed consent despite having been trained to understand its importance.

In India, patients are enrolled into research studies without their knowledge. Recall the tragic People’s Hospital fiasco in Bhopal late last year, where hospital workers inducted marginalised, illiterate and job-seeking people into the phase 3 trial of Covaxin without their knowledge and with promises of money. Despite their egregious nature, it is hard to know the true prevalence of such practices, since trial researchers simply report that, yes, they do have informed consent.

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Such practices are especially common in observational studies: when researchers don’t test an intervention (like a vaccine or a drug) but use medical history data, surveys, laboratory tests and physical examination to arrive at conclusions. For example, doctors may take blood samples from admitted patients on the pretext of diagnostic testing and run tests on them for their research. Observational studies generally have a low potential to cause harm, but not getting the patient’s consent violates their autonomy and is deceitful. Interventional research projects, like clinical trials, tend to be more compliant with consent-obtaining protocols because of the dire consequences of failing to do so. This said, remember that the People’s Hospital fiasco happened anyway.

Overall, it would be fair to say that the extant Indian medical ecosystem by and large disregards patients’ rights and places little store by the code of medical ethics. Training in such a dysfunctional system is likely to produce more misinformed doctors that then leads to a vicious cycle that, ultimately, can cultivate only a contemptuous care-giving setting.

The NMC’s new MBBS curriculum includes an ‘attitudes, ethics and communication’ portion, or AETCOM, designed with an aim to produce doctors who practice more ethical medicine. However, it seems likely for now that AETCOM may be limited to theory – something for students to study ahead of exams. This is because it is hard to explore the practical implications of unethical medicine without training students in the clinical setting, and without also increasing awareness among patients of their rights and without stronger laws to ensure care-providers do the right thing.

Amulya Gupta is pursuing an MBBS at the All India Institute of Medical Sciences, New Delhi. He is part of the India COVID Apex Research Team (I-CART), and recently started a patient education website, He tweets at @dramulyagupta.

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