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1993 SMA Lecture

NO MAN IS AN ISLAND

 

N K Yong

 

(Lecture presented at the 24th SMA National Medical Convention)

 

 

Mr Minister, Mr President, our distinguished Guests, fellow members of the SMA, 1 thank the Singapore Medical Association for this great honour of being invited to deliver the Singapore Medical Association Lecture for 1993.  It is a Lecture I take great pride in giving and it is a great platform, but it is one that fills me with much anxiety and trepidation as there have been many much more distinguished Lecturers before me.

 

This Lecture as most of you do know traditionally deals with ethical issues and related subjects.

 

The Hippocratic oath on which our modem Ethical Code is founded goes back four centuries before Christ.  That was a long time ago.  It has undergone some changes since then, modem interpretations have been enshrined in the Declaration of Geneva, in the International Code of Ethics, and the Declaration of Helsinki in 1964, and most recently in the Commonwealth Medical Association Ethical Code.  Some of the provisions discarded with the passage of time included for instance the prohibition of physicians to \"cut persons labouring under the stone\".  Today the removal of kidney and gall-stones is commonplace because these have become safe procedures.

 

The Hippocratic oath also forbade the \"giving (of) a woman a pessary to produce abortion\".  We still do not give pessaries to cause abortion, but in many countries now abortions are sanctioned by law, though not necessarily always with the happy agreement of the profession. I quote one more Hippocratic commandment which is today the subject of much heart-searching amongst us - \"I will give no deadly medicines to anyone if asked, nor suggest such counsel.\" This most sacred and honest of our Hippocratic commandments, is now the subject of very divisive debate, the debate about euthanasia.

 

The issue I am addressing in my lecture today is clear -Are our ethics the product of our times?  Is not some of it timeless and totally immutable?  And if some of it should endure, what part of it can and should we hold fast to.

 

We live in a world that is at the same time discomforting as it is comfortable. I have been a practising doctor for over forty years.  It was much easier during the years of my early career to practise medicine.  The public institutions were the only source of employment, it was accepted that most of us would spend most of our working lives as staff of the Ministry or the University.  Salaries were not munificent but by the standards of the day they were adequate.

 

There was no private specially practice, the doctors in town were family or general practitioners, and they were by and large a fine breed.  The general practitioner was someone who commanded a lot of respect within the community.  They were the pillars of the community, and rightly so.

 

The changes began some thirty years ago.  A few specialists began to put up their plates outside - gynaecologists, surgeons and anaesthetists - the surgical specialities.  The migration from the public hospitals was gentlemanly.  Consultants as they neared retirement age left the service for the town.

 

But as private hospital facilities opened up, and more and more patients chose private in preference to public hospital and medical care, specialists and consultants began to leave the service earlier.  Indeed some left shortly after they had completed the Fellowship or Membership examinations.

 

We have within the space of thirty years, within the lifetime of one generation, bounded into the medical world of the twenty-first century.  We have about six times as many doctors today as we had thirty-years ago, andforty percent of them are specialists.  We have a doctor-population ratio today of one in 830, and the target is one in 650!!  Private hospital admissions comprised 23 percent of all admissions in 1991. 1 do not wish to burden nor bore you with statistics. 1 quoted a few to show how much and how fast the scene has changed - and how these shifts have affected the structure and character of healthcare in this country.

 

This radical transformation of the healthcare scene is neither to be regretted nor to be applauded.  It has happened and that is the reality.  To live is to experience change.  The change has come about for many reasons, one of the most significant of which is rising affluence.  It is in the nature of human kind to aspire and strive upwards, a natural development of man\'s primeval instinct for survival.  Maslow spoke of a hierarchy of needs, the basic ones of food and safety being primarily survival-oriented.  When basic needs have been met, man turns to what Maslow has termed \"Meta-needs\", needs to increase creature comfort and satisfy vicarious desires.  How do we cope with this change?  How well are we coping?

 

In this changed scene, patients seek more personalised health care, and doctors seek more financially-rewarding and comfortable existences in private practice.  We are caught up in what is essentially a world-wide wave of upward movement.  We can no more stem it than could King Canute have stopped the advancing tide.

 

We have gone very far and very fast - have we gone too fast, and in our almost blind and unthinking haste, not so much forsaken the bedrocks of our noble profession as become anaesthetised by success, meaning money.  Anaesthetised to the extent that expediency, compromise, and taking comfort and refuge in being part of the masses now govern our professional conduct and our interpretation of our Ethical Code, and indeed dulled our collective conscience.

 

But we make noises - we decry the Commercialisation of medicine, and we blame the Government, we blame the public, the media, everyone except ourselves.  We point out that the National Economic Plan produced some ten years ago when Singapore suffered its biggest recession, concluded that Health Care should be targeted as a growth industry.

 

What exactly do we mean by commercialisation, what specifically do we have in mind?

 

Medical care has become expensive, not only here but all over the world.  Hospital care is expensive, even in the restructured hospitals.  The thrust of the Government\'s healthcare programme is to provide high-quality care without inordinate increase in the healthcare budget by shifting more and more of the personal cost to the individual.  The individual must take increasing responsibility for his own healthcare costs.  There is everything logical and sensible in that policy.

 

The scheme to allow full-time consultants and specialists to keep virtually all the fees earned from their private patients was an attempt to reduce the gross disparity between public and private incomes.  It was thereby hoped that this would reduce the brain drain into the private sector.  It did not work.  Staff still left.  Thankfully the scheme has now been changed.

 

Another important area which is currently receiving attention, much belated it must be said, is a properly regulated official Register of Specialists.  The SMA had been urging the Ministry for years to do this.  Until there is an official Register, anyone can pass himself off as a specialist, and charge an unsuspecting public accordingly, surely not a desirable situation.

 

The introduction of medical lasers into Singapore about seven years ago led to unregulated and unqualified use by some specialists and general practitioners alike.  LASER CLINIC FOR WOMEN in big lettering announced one clinic on its signboard.  Admittedly only a few were involved, as the majority of the profession retained their sense of proportion and propriety.  Last year the Ministry introduced laser licensing for doctors and so such blatant advertising may be a thing of the past.

 

The spate of prominent and sometimes tasteless reporting in the public media of world-best results in such high-profile avant-garde medical activities such as in-vitro fertilisation (IVF) by institutional consultants is thankfully diminishing.  Protests by the SMA that such conduct was at best unseemly and unbecoming, at worst smacking of indirect advertising, were met with replies that the public needed to be informed and educated.  We have a right to be proud of our achievements, but let us remember that we also have a duty as professionals and scientists to be factual and accurate, and that our results and findings should be measured against world-wide accepted criteria.  We would like to think that the vigilance of the SMA\'s Ethics Committee played an important role in keeping such unprofessional conduct to the minimum.

 

The implementation at the beginning of this year of the Private Hospitals and Medical Clinics Act which was originally passed some ten years ago is most welcome.  It is the single most refreshing and exciting new development that has taken place in Health Care recently.  For the first time, there is a real attempt to ensure that hospitals meet defined and well accepted standards.  The Bill took a long time to be activated.

 

The high cost of medical care has been blamed on commercialisation.  Services will always cost more than goods.  Increased productivity lowers production costs to a far greater extent than cost of services.  The pharmaceutical industry is the latest whipping boy.  They are not blameless, but few appreciate that development costs are high, and must be met.

 

To be paid for our services is our due.  We should be paid and paid equitably.  The labourer is worthy of his hire.

 

Patients understand now that they need to pay us for our services, and when it comes to private specialist medical care they know that it is not cheap.  The poor general practitioner is the one who gets squeezed.  The public still expects him to charge less than ten dollars.  When the Singapore Medical Association promulgated its first schedule of fees, and recommended a consultation fee of ten dollars for general practitioners the Sunday Times ran huge headlines on its front page in large capitals \"Atchoo, and that will be ten dollars\" - an emotive headline if ever there was one.

 

To put that fee into its correct perspective, a haircut, no trimmings, in those days cost five to ten dollars.  The TV repair man charges twenty-five dollars for transportation before he even looks at your TV set.  And the same Singaporean raises a hue and cry because his family doctor charges him ten dollars consultation fee - for professional services only, no medicines.  Unfortunately we must ourselves bear part of the blame.  Notwithstanding the SMA\'s recommendations, consultation fees as low as two dollars are being quoted in tenders for contract practice.  If we value ourselves so lowly, can we wonder that our public image is correspondingly low?

 

In the few examples I have laid before you one recurring theme stands out.  Right at the centre of the maelstrom stands the doctor.  There are four parties involved in the delivery of healthcare.  There is the patient, the Government, the third party payer, and there is the doctor.  And of these the key player is the doctor.

 

There is another major theme, perhaps less obvious, perhaps because we do not want to see it.  The fact is that money features prominently at the centre of almost every discussion.  It is the most important, it receives the most attention.  Not standards, not quality, not good honest doctoring - just plain money.  What we really mean when we refer to the commercialisation of medicine is the materialism that now permeates every fibre of the fabric of our society.

 

We have lost our way.  We have turned from being a profession with a commitment to people, to a profession with a commitment to ourselves and the good things of life.  The profession is seen as a good means towards that end.  We see medicine as a business primarily, and as a service profession very much secondarily.

 

I accepted that I may be an anachronism, that I am out of step with the times.  Be realistic 1 am often told.  But what is realism?  Are we to accept that our Ethical Code is no longer relevant?  I do not believe that it is possible.  In a world in which materialism is the all pervading influence, in which expediency, pragmatism and convenience have replaced honesty and honour and belief in one\'s self, there is an even greater and more urgent need for us to stand firm and defend our Code - not only defend but live and practise it.

 

I have referred to the doctor as the key player on the healthcare scene.  Indeed he is.  It is the doctor who makes the diagnosis, who orders the investigations, who plans and sometimes even carries out the treatment.  Every other element in healtheare revolves around and is dependent on this.

 

We can practise with honesty and integrity, with commitment and sincerity, with compassion and humanity.  We can practise with our patient as our primary responsibility, without fear or favour, regardless of race or creed, regardless of sexuality, regardless of financial considerations.  If we steadfastly maintain this, we will play our part in keeping healthcare costs from escalating unjustifiably.  Good doctoring keeps costs down.  We can do this, and still earn a good living.  Our wealth will not necessarily be measured by our bank accounts, our stocks and shares, our property, and all other mundane measures of affluence.  We will have pride in ourselves.

 

I come full circle now to the issue I raised at the beginning.  Is our ethics the product of our times?  My answer for your consideration is that that part of it which was the product of a different time and technology and stage of knowledge needed to be amended.  But the core of our Code remains independent of our times, independent of science and technology, independent of boom or recession, independent of governments and man-made systems.  No one can take that away from us if we do not allow them to.

 

We do not function as isolated islands within the community.  The community is also us.

 

\"No man is an island,

entire of itself,

every man is a piece of the continent,

part of the main

- John Donne 1571- 1631

 

We can follow or we can lead.  The choice is ours.

 

Men at some time are masters of their fates;

the fault, dear Brutus, is not in our stars,

but in ourselves,

that we are underlings

            - Shakespeare, Julius Caesar.

 

To see a world in a grain of sand,

and a heaven in a wildflower,

hold infinity in the palm of your hand,

and eternity in an hour.

          - William Blake, Auguries Of

          Innocence. 1757 - 1827.