Between Professionalism And Pecuniary Benefits

News Introduction: 
Medical doctors in Nigeria abandon the Hippocratic Oath which they swore at induction for pecuniary benefits. - By George Emine and Arems Terkula

David Owudaba rushed his friend, Anderson, who was attacked and was in a pool of his blood to a popular private hospital in Wuse Zone 6, Abuja.  With a shattered head and bleeding wounds all over his body, David was asked to pay a consultation fee of N6, 000, which he did promptly.  But despite the fact that Anderson was in a very critical condition and was unconscious, the medical personnel insisted that David would pay an additional N28, 000 before they could commence treatment despite pleas by the family.  Devastated, David asked that the initial N6, 000 be refunded to him since he wasn’t told he would pay an additional N28, 000 before his dying friend would be attended to, but he was told the consultation fee was nonrefundable.  David felt swindled.  He had to take his friend to the Wuse General Hospital, which was much farther away, and fortunately, he was attended to and eventually his friend survived.  Doctors at the hospital said further delay would have made his chances of survival very slimmer.
Such scenarios play out in most private hospitals in Nigeria and even in general hospitals.  While emergency cases are rushed to the hospitals due to proximity, many of such patients do not get the required life-saving treatment as medical personnel put financial gains ahead of their primary duty to save lives.  
Not too long ago, over 700 doctors in the employ of the Lagos State government were sacked for embarking on an industrial action. It took the intervention of people in high political offices before they could be recalled.
Incessant industrial actions by medical doctors have made members of the public to lose respect for the noble profession.  The number of lives lost during these industrial actions is usually very painful, which would have been otherwise, avoidable.  Most of the times, emoluments and better conditions of service have been the reasons behind most of these strike actions. 
During the nationwide strike protests against the hike in price of petrol in January this year, which was declared by coalition of civil society groups, the organised labour and the Nigerian Bar Association, the Nigeria Medical Association, NMA, directed its members to join the n strike.  President of the NMA, Dr. Omede Idris, who gave the directive at a news briefing, said that the association had consulted widely with all its state branches and senior members of the profession before taking the decision. This is in spite of the fact that some protesters in the process might be injured and might require medical attention or there might be pregnant women who might be in labour. 
In Anambra State, doctors in the state public hospitals were on strike for over one year.  The 13-month old strike was only suspended in February this year, when it apparently became obvious that the state government was not ready to shift ground on the 60 percent salary increase it offered the doctors when the strike began last year.  The doctors embarked on the strike over the state government’s alleged refusal to implement the Consolidated Medical Salary Structure, CONMESS, approved for doctors working in government-owned hospitals in the country.  Dr. Emmanuel Ekwesianya, chairman of the branch of NMA, said despite efforts to make government shift ground, it remained rigid on the 60 percent increase it offered to pay the doctors when negotiations began.  And in all these cases, so many have lost their lives.
Strike actions by doctors often meet with a great deal of resistance not only from the public but from within the medical profession. It is seen as unethical and a negation of the 2000-year-old Hippocratic Oath. Unfortunately, most of these strikes have caused lasting damage from which health systems have struggled to overcome.  In the case of Lagos State, where the strike action by doctors led to the sack of about 788 doctors, the Head of Service, HoS of the state said in a statement that while the doctors had the right to declare an industrial dispute, they also had a duty to serve notice on government so that adequate preparations could be made to monitor patients on admission in hospitals.  “The decision of the doctors under the Medical Guild to abandon the hospitals without the notice stipulated by law caught government by surprise and led to many deaths. No responsible government will tolerate that.” He argued that in developed countries, the medical doctors would have had to deal with criminal suits from patients for abandoning them in the hospitals. “It is begging the question to accuse the state government of attempting to decimate the medical profession when indeed the government had invested heavily in human personnel and physical infrastructure in the health sector to globally acknowledged level,” the Head of Service explained.
Another troubling issue is the way doctors in government-owned hospitals refer patients to private hospitals for treatment. Investigations by this magazine revealed that most times, these private hospitals where patients are referred to are either owned by these doctors or they have interests or shares in them. According to Dr. Abdullahi Bako, a retired public health practitioner, “the common trend among medical practitioners these days includes building their own private hospitals or pharmacies where they refer patients to patronise their business.”  
Erdoo Bem was referred from the Wuse General Hospital, to a private laboratory to run an EEG test, only to find out that the doctor who referred him also works part-time there.  After making enquiries, he discovered that he would have run the same test for just N8, 000 at the hospital instead of the N30, 000 charged at the private laboratory.  Okon Emmanuel suffered a similar fate after he was rushed to a public hospital in Lagos to treat his broken leg. In his case, the consultant referred them to his wife’s pharmacy but after buying the surgical kit, the procedure was changed, but the kit was not returned to Okon.
The latest trend, which has become a money spinner for hospitals especially in the Abuja, is centered on child delivery.  Before a woman goes into labour, medical practitioners would ask the husband to ensure at least two pints of blood is either donated or bought in advance.  They claim it is a preventive measure but investigations have shown that in about nine out of 10 cases, the blood is never needed or used but it automatically becomes the property of the hospital.  In other emergency cases, this blood is being sold and the proceeds of course go to the medical personnel or the hospital, as the case may be.  “This is their latest racket,” Mr. Omoniyi, who had to donate two pints of blood for his wife, told this magazine.  “I never knew, so I fell to their antics.  It was later that I was told that it was their new way of getting blood which they later sell to those in need.  Because of the anxiety, you will immediately oblige them, but most times they know they would not need it,” Mr. Omoniyi said.  And like him, many unsuspecting husbands and other family members have fallen to this ploy. Blood Group O negative (O-) is sold for as much as N15, 000 per pint in private laboratories and blood banks in Abuja.
Professor Onyebuchi Chukwu, Nigeria’s minister of health, is disturbed by this emphasis on money against the lives of patients.  The minister, who was at the Nigerian Newsworld Leadership Forum, decried how some doctors refer patients to foreign hospitals for treatment for cases that would have been easily and successfully handled in Nigeria just because a percentage of the medical bill goes to the doctors.  He said this accounts for the increase in referrals abroad for treatment.   “The situation whereby Nigerians are going abroad for treatment is the most disturbing to me as minister of health. Some unscrupulous doctors and health practitioners because of money made from such trips often refer patients abroad for commercial gain,” the minister said.
Like the health minister, the Medical and Dental Council of Nigeria, MDCN is also worried.  In July last year, the council had to wade into the incessant industrial actions by medical personnel. Chairman of the Council, Dr. Roger Makanjuola, told newsmen in Abuja that sanctions awaited any practitioner that flouted the new directive agreed upon at their last stakeholder’s meeting. The highest medical decision making body in Nigeria, however, added a caveat that it was only in extreme cases that doctors would henceforth be allowed to embark on strike. He said that even in such extreme cases, certain measures must be put in place before doctors could abandon their duty posts.  “It is unethical to go on strike. Practitioners must respect the provisions of the Code of Medical Ethics in Nigeria as prescribed by the MDCN. Having sworn to the Hippocratic Oath, doctors should not go on strike because the oath says, first, ‘the health of my patient shall be my first consideration’ and secondly that ‘I will maintain the utmost respect for human life.’  These two components of the oath are clearly in conflict with strike actions. If we do not intend to abide by the Hippocratic Oath, then we should stop swearing to it,” Makanjuola said. “The Code stipulates that no patient can be abandoned in the midst of his or her treatment. A striking doctor must make arrangements to hand over the continued care of his patients before he leaves his post.  Also, provision must be made for the continued provision of services for accident and emergencies and the care of those with serious illnesses and life-threatening conditions.”  But events since this declaration still prove it is far from being achieved.
A medical student usually looks forward to a career of life-saving, and appreciation and respect for life. Before choosing this path, students are carefully advised not to choose this career for the money or other material gains, but for the desire to save lives. The International Code of Medical Ethics (otherwise known as Venice 1983), enumerated as part of the duties of physicians in general to include to “always maintain the highest standards of professional conduct” and “not permit motives of profit to influence the free and independent exercise of professional judgment on behalf of patients.  A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence or who engage in fraud or deception.”
It also condemns as unethical conduct,  “paying or receiving any fee or any other consideration solely  to  procure  the  referral  of  a  patient  or  for  prescribing  or  referring a patient to any source.”
On its part, the General Principles of the Ethics of Medical and Dental Practices in Nigeria states among other things that: “The principal objective of the medical or dental practitioner shall be the promotion of the health of the patient. In doing so, the practitioner shall also  be  concerned  for  the  common  good  while  at  the  same  time according full respect to the human dignity of the individual.”
The Code of Medical Ethics in Nigeria also states in its introduction that, “every medical and dental practitioner should familiarise himself or herself with the provisions of this Code, so that he or she would  practice  the  profession  with  conscience  and  dignity,  within  the  limits  of  the provisions of the Code, thus bringing the incidence of ethical violations - to the barest minimum.”  It also states further that, “every member of the medical or dental profession must endeavour to abide by the dictates of the Physicians’ Oath, the modern version of the Oath of Hippocrates, which is the foundation of the Code of Ethics of the profession.  Embodied  in  this  oath  are  the  guidelines  for  behavioral  interaction between practitioners and their patients, practitioners and their colleagues, practitioners and their teachers as well as practitioners  and the public as represented by the law and the government.
The lack of respect for the Hippocratic Oath has become an embarrassing issue for medical practitioners themselves so much that nobody wants to discuss the issue especially in the media. The Hippocratic Oath formulated in the Fourth Century BC is the most enduring tradition in Western medicine and has been the guiding ethical code for physicians since then. The Oath widely respected by doctors worldwide emphasises the depth of the medical covenant, which hinges on patient’s dignity, the privacy of the transaction, and the physician’s responsibility to guard against abuse or corruption of his knowledge and art.
But the national coordinator of the Human Rights Writers Association of Nigeria, HURIWA, Comrade Emmanuel Onwubiko, while looking at the human rights issues occasioned by strike actions embarked upon by medical doctors, said it was a two-way problem which affected the patients and the general public on the one hand and the medical doctors on the other hand.  While condemning the loss of lives during these industrial actions, Onwubiko maintained that medical doctors could not be completely bared from embarking on industrial actions when such became necessary. “Strike is a constitutional right.  If you have a disagreement with your employer, you have the right to go on strike. If the conditions of service of workers are not met, they are obliged to go on strike. The medical doctors are workers and they also have their rights as members of a professional body; they can go on strike as a last resort, but because of the very sensitive nature of the work they do, I think before the medical doctors should go on strike, there has to be an alternative arrangement from them to set up emergency medical facility because there are certain category of patients that cannot afford the high fees charged by private hospitals.  They can also run units that can provide voluntary medical services to the less privileged.”
But Comrade Onwubiko condemned the situation whereby medical doctors put monetary considerations ahead of the lives of patients in emergency conditions.  “It is not completely correct for doctors to abandon patients or watch them die because of the inability of the patients to immediately pay for an emergency medical service,” he said.


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