University of the Philippines in Mindanao Recognition for 2016

Our ethical formation as doctors begins early. My ethics was greatly formed in college. It shaped my ethics in my responsibility as doctor to the society. Earlier this week, I was informed that I am being recognized by my college Alma Mater as one of the Most Distinguished Alumni of UP Mindanao for 2016. Below is what I had to say:

Salamat sa mga nagbigay ng parangal na ito. Pero ano nga ba ang ibig sabihin ng parangal na ito? Para sa akin, ang tanong ay ano nga ba ang puedeng magawa ng isang estudyante ng UP Mindanao 20 years mula ng kanyang unang  enrolment? Opo, 1996 po kasi ang aking student number.

Sa loob ng 20 years, dapat po sana ay graduate ka na. Dapat sana ay tapos ka na sa pag-aaral mo at ikaw ay may trabaho na para kumita at may sarili ka nang pera. Para naman hindi ka na hingi ng hingi ng pera sa mga magulang mo. Maawa ka naman sa kanila kung sa loob ng 20 years ay humihingi ka pa rin ng pera hanggang ngayon. “Ang makagradweyt at makahanap ng trabaho.” Ulitin ko. Ang makapagtapos ng pag-aaral para makahanap ng MAGANDANG trabahong magbibigay sayo ng MAGANDANG sweldo ay HINDI po tinuturo sa UP. Hindi rin po yan ang natutunan ko sa UP, kaya alam kong hindi rin po yan ang ibig sabihin ng parangal na ito.

Noong kami ay nasa PCA compound pa bilang mga estudyante, ang tinuro sa amin ay kung paano makitungo sa ating kapwa tao mula sa iba’t ibang antas ng buhay. Noong kami ay nasa Pahinungod at umakyat ng Diwalwal o sa Boys Town ay tinuro sa amin kung paano pahalagahan ang kapakanan ng iba higit sa sarili. Noong kami ay volunteer sa Eagle Center at binabantayan ang Agila sa Arakan Valley kahit may panganib, tinuro sa amin kung paano pahalagahan ang kalikasan. Noong kami ay dumalaw sa mga komunidad ng Mandaya, Bagobo at Tboli ay tinuro sa amin ang kahalagahan ng ating kultura. Noong kami ay naglakad sa lansangan ng Magallanes at Claveria, natuto rin kaming ipaglaban ang katarungan. Noong kami ay umakyat sa bundok ng Hamuigitan at noong nagsurvey sa Davao Gulf ay tinuro sa amin ang kahalagahan ng pagtuklas at pagsaliksik ng bagong kaalaman. Hindi po PAANO maghanap buhay ang tinuro sa UP.

Ang natutunan po naming ay paano maglingkod sa kapwa, sa kalikasan, sa Diyos at sa Bayan. Pagkalipas ng 20 years, ano nga ba ang puedeng magawa ng isang estudyante mula sa UP Mindanao? Walang iba kundi ipagpatuloy ang nasimulan at natutunan sa UP. Ipagpatuloy ang tamang pakikitungo sa kapwa, ipagpatuloy ang pagtulong sa mga nangangailangan, ipagpatuloy ang paghingi ng katarungan, ipagpatuloy ang pangangalaga sa kalikasan, ipagpatuloy ang pagtuklas sa bagong kaalaman, ipagpatuloy ang pagsulong ng kaunlaran, at ipagpatuloy ang paglingkod sa bayan. Opo, pagkalipas ng 20 years ay hindi pa rin po ako tapos sa pag-aaral dahil estudyante pa rin po ako sa UP. Pero salamat po sa pagkilala sa mga gawaing itinutuloy lamang natin.

At ang pagkilalang ito ay pagkilala rin sa mga katuwang natin sa mga gawaing ito… ang mga taong tumulong sa atin sa komunidad, mga lider ng people’s organization, Civil Society groups, mga nakatrabaho ko at fellow development workers, mga kaibigan kong nagbibigay suporta at panalangin (sana dagdagan niyo ang inyong donations), mga fellow Pioneers (sayang at wala ng UKLAS Mountaineers) mga naging guro ko lalo na dito sa UP hindi ko na po kayo iisa-isahin (pero especial mention kay Ma'am Novero na nagtiwala sa ating kakayahan) at sa mga una kong guro... ang aking ama at ina; ang aking pamilya na lagi kong kasama at higit sa lahat si Bathala.

Daghang Salamat. Padayon…

AMDG... To God be the Glory...

Effective Altruism and the Ethics of Helping Others through Medical Missions

Effective altruism has been a major concern about the ethics of helping others. The discussion has centered on whether the help we offer has the greatest positive impact to the world. It scrutinizes whether the intent to help others is a valid reason enough to use our resources in certain activity. Such is the ethical questions that needs to be addressed by organizations thinking of maximizing their resources to help others through a medical mission. Here are Six Questions that needs to be answered before you organize a medical mission:


1. Is the medical mission the best way to improve the health of the individual and the community at large?
Medical missions are useful when disaster strikes as the health care system is overwhelmed by the situation. Yet, in ordinary times there are existing health services that the government are offering. It might be more effective to help improve the existing health programs and services available in the community to have longer lasting impact in improving people's health and the community as well. It It is better to put your resources to a program that will provide the greatest benefit to most number of people.


2. Is the medical mission needed in the area?
Many medical missions are conducted in areas that do not match the resources available to the needs in the area. One group once went to a depressed squatters area bringing antibiotics expecting many sick children. They found many to be sick with tuberculosis but do not have the medicines for it. Because medical missions often address acute medical needs, the timing and the location are important considerations for this activities. Another location might benefit the most with what you have to offer.


3. Are the recipients the neediest people who need the service?
This question is related to the first. Medical missions are often limited in their resources. It becomes important then to ask who will receive these limited resources? Do we give these to members of the organizations only? Do we invite our family and friends? Do we cater on a first come, first serve basis? Or do we exclusively limit it to the poorest people who needs the help the most?


4. Is the "medical mission" helping the local health system?
Each locality has an existing health care system. In low-to-middle income countries (LMIC) like the Philippines, it might not be as effective as we want it. But are the medical missions we are conducting helping the system or are we competing against them? Check if there are local health centers and health workers in the area. It will be unfortunate to conduct medical missions without their participation. You might miss creating a bigger and lasting impact.


5. Is the medical mission highly dependent on donations?
Do you conduct the medical missions on a regular basis or only when the resources are available? How will this impact continuity of health care to the people? If the reason why the medical mission was done in the area is because medical services are really needed, what does it mean to provide only once in a "Blue Moon" health services to them or only when resources are available? Limited resources is better placed in programs with the greatest health outcomes for all.


6.  Is the group concern with the health of the people or are they just using it as leverage for their own purpose?
What could be the driving force for the medical mission? Some churches have conditions for the beneficiaries, they offer only medical services only after the beneficiaries have participated in a Bible Study by the group. Politicians leverage it for their election. Groups use it to promote their products. Or do they simply want to help improve the health of the most number of people regardless of nothing to gain in return?


Effective altruism does not question the intent of the people to help others. For many utilitarians like Dr. Singer, they question the impact and effectiveness of the help offered. Effective altruism, thus, puts into proper perspective how medical missions can effectively impact the health of the wider-community. Were the resources used properly? But for virtuous doctors, the question really is, can the medical missions effectively help me become a virtuous doctor? Are the medical missions the best venue in forming in me virtues that will make me an excellent doctor?  For Christian doctors, can these medical missions be the best way for us to achieve Christ-likeness? Will these activities form in me virtuous of magnificence? Do I practice generosity?

For in generosity, I am helping the best way I can to a person who needs me most.

Can I back date a Medical Certificate?

My resident doctors have been asking me what to do if they have patients who request to backdate their medical certificates.

"Sir, I have several patients come in to request for medical certificate because they want to be excused for their absence. Given that it is true, can we help them be excused so they get their salary by backdating the medical certificate? Is this ethical or not?"

For the sake of ethical discussion and not considering the legal implications, do you think it is ethical or not?

Veracity is the ethical principle of truth telling. Deontologists will tell us that doctors are duty bound to be truthful in their actions. Utilitarians will argue to do the action that will benefit the most good to all. But what about the character and values of the doctor that they must exhibit?

Truthfulness is a virtue that humans, especially virtuous doctors possess. What then should a virtuous doctor do when faced with a similar situation where a patient asks him to backdate a medical certificate? A virtuous doctor is expected to be truthful and would not lie about the date written in the medical certificate. He might, however, truthfully put a remark that the patient may have been sick for several days covering the dates that he was absent.

How do you make an ethical decision?

How do you make an ethical decision? I always get this question from my students.

While researching for recent trends in ethical thinking, I came across the Ethics webpage of Santa Clara University. Here, I was reintroduced to this framework for ethical decision making. We have tried using this framework in the monthly Ethical conference we have with medical interns in a government hospital in Manila. What is good about this framework is that it allows the medical students to think ethically. During the conference, medical students engage with each other and discuss which ethical standards will guide them in making a decision. (Watch out for my next entry on their discussions.)

Here is another example of making an ethical decision.

Below is a useful guide for ethical decision making whenever you encounter ethical issues. 

 A Framework for Ethical Decision Making

Recognize an Ethical Issue

1.       Could this decision or situation be damaging to someone or to some group?

Does this decision involve a choice between a good and bad alternative, or perhaps between two "goods" or between two "bads"?

2.       Is this issue about more than what is legal or what is most efficient? If so, how?

Get the Facts

1.       What are the relevant facts of the case? What facts are not known? Can I learn more about the situation? Do I know enough to make a decision?

2.       What individuals and groups have an important stake in the outcome? Are some concerns more important? Why?

3.       What are the options for acting? Have all the relevant persons and groups been consulted? Have I identified creative options?

 Evaluate Alternative Actions

1.       Evaluate the options by asking the following questions:

Which option will produce the most good and do the least harm? (The Utilitarian Approach)

Which option best respects the rights of all who have a stake? (The Rights Approach)

Which option treats people equally or proportionately? (The Justice Approach)

Which option best serves the community as a whole, not just some members? (The Common Good Approach)

Which option leads me to act as the sort of person I want to be? (The Virtue Approach)

Make a Decision and Test It

1.       Considering all these approaches, which option best addresses the situation?

2.       If I told someone I respect-or told a television audience-which option I have chosen, what would they say?

 Act and Reflect on the Outcome

1.       How can my decision be implemented with the greatest care and attention to the concerns of all stakeholders?

2.       How did my decision turn out and what have I learned from this specific situation?

 This framework for thinking ethically is the product of dialogue and debate at the Markkula Center for Applied Ethics at Santa Clara University. Primary contributors include Manuel Velasquez, Dennis Moberg, Michael J. Meyer, Thomas Shanks, Margaret R. McLean, David DeCosse, Claire André, and Kirk O. Hanson. It was last revised in May 2009. - See more at: http://www.scu.edu/ethics/practicing/decision/framework.html#sthash.rMJW1mW5.dpuf

 

3 Common Unethical Scenarios on Doctor - Doctor Relationship

A friend posted in Facebook how one doctor did not show good ethical practice when he was receiving a referral from a fellow doctor. I remembered writing a brief essay about the doctor-doctor relationship years ago in my personal blog theomed.blogspot.com. I'm sharing an edited version below:

Human pride is one of the pitfalls of human nature. But this is not an excuse to disrespect others. That is why a physician is virtuous enough to know what to do and how to foster good relationship with ones colleagues. Yet, young doctors and even their mentors get drunk of their title as doctors that they forget their ethics.

 

Here are 3 common scenarios of unethical doctor-doctor relationship:

 

1. Maligning a colleague

 

A patient comes in with a referral letter from a family physician for the pediatric patient to be admitted because of Dengue. The pediatrician refuses the patient to be admitted because she did not see any indication for the patient to be admitted. The pediatrician may be right and she has all the right reasons for refusing the request for admission. What went out of bounds is her remark against the referring doctor. She comments that the referring doctor is ONLY a family physician and his decisions should not be accepted. Here, the pediatrician is obviously insinuating that the other doctor is inferior to her. More than that, she shows disrespect by maligning the knowledge and the decision of her colleague. Hers is one example of utter DISRESPECT that have plagued the medical practice in hospitals. We, as doctors, have forgotten the basic principle in our code of conduct - that we should work together in harmony and mutual respect.

 

2. Delaying or refusing referral

 

Another example of disharmony in the workplace of doctors is the referral system in government hospitals. I will emphasize the government hospitals, because these things rarely happen in the private setting. A surgeon refers his diabetic patient to the internist for control of the blood sugar and clearance for surgical procedure. The internist delays seeing the patient, as a retaliatory act to what he claims the surgeon is doing whenever he refers also for surgical clearance of his patients suspected of having surgical abdomen. The patient is the one suffering from such behavior of doctors. The patient, of course, complains his surgeon to the hospital authorities for not being able to refer and resolve his case quickly.

 

 

3. Side comments

 

The most common problem perhaps, leading to the numerous malpractice suits, is the side comments doctors make to their colleagues. An example is the Internist who saw a Pulmonary TB patient who sought second opinion after being seen by a private doctor. The Internist comments to the patient, "do not seek consult to this doctor again. Did you know that it took him several years to finish medicine because he flunked his subjects. Look, he did not even recognize that you have tuberculosis. And why did he give you pulmonary medicines that can compromise your liver. That doctor will just make you more sick." That may be exaggerated but even simple side comments like, "hindi ka niya chineck-up ng mabuti (he did not give a complete physical exam)" undermines your colleagues skill and practice. Such comments are unwarranted, but in reality, such comments exist. What virtuous doctor in their right mind, would comment such derogatory remark about their colleague?  

 

In the quest to advance the practice of medicine, doctors have forgotten about their virtues and ethics. Ethics has been neglected for a long time. It is now the time to check the virtues of our doctors. A virtuous doctor can never and will never intentionally hurt his/her fellow human being, regardless if he/she is a patient or a colleague. We can never go wrong with a virtuous doctor. I encourage you to push and demand for our doctors to check their ethics, and be virtuous!

3 Reasons Doctors Do Not Join Medical Missions

I often get invites to join medical missions. But as a public health practitioner we know that short term "Band-Aid" solutions are not enough to improve the community's health. I can not just give anti-hypertensive drugs to a person, I must ensure that the diet of the whole family is modified, the physical activities are changed and the wider community advocates for changes in government policy, regulate sugar and salt content in foods, set up parks for exercises, put bike lanes in city streets among others. The entire health system must be involved and all other sectors must participate. I am sharing a blog-post from theomed.blogspot.com on the 3 reasons doctors who believe in community-oriented primary care do not join medical missions.

 

It is becoming difficult for organizers to get doctors to join them in their medical missions. I am not an advocate of medical missions. Before I give you the reasons why, let me clarify that what we mean of medical missions are the trend today of one-time events of medicals consults and surgeries with giving of medicines to patients as a tool for achieving something else. Med missions are sometimes beneficial especially during emergencies but other than that, it is an ineffective practice.


Here are three reasons why:

1. Medical missions do not address the health problem.

The medical management does not address the cause of the problem. A patient may come in with Tuberculosis due to the poor sanitation of the area, or poor nutrition, or poor hygiene habits. The current trend in medical management today is holistic approach wherein the doctor not only intervenes at the medical condition of the patient but also considers the other factors surrounding the patient. These factors include the mental, social and spiritual factors. Medical management also includes patient education on how the patient can improve her living condition, environment, lifestyle and other things more than just taking the prescribed medicines. This may not be possible as time is not a luxury during med missions. Also, some cases like TB needs further patient care which leads us to the second reason.

When Jesus healed the lepers, he restored their relationship with society. Remember, patient care is more than just treating the disease.


2. Medical missions do not provide continuing patient care.

Proper medical care is continuous and personalized. When medical missions are one time event, it does not allow for patient to follow-up with their health care provider for continuing care. Imagine the popular summer medical mission providing free circumcision to young boys. If complications happen to the wound, how will the boy get follow-up care from the healthcare giver? Even if complications do not happen, the healthcare worker are ethically bound to continue care to the patient until they are well. This will not happen in one-time medical missions. Because of time constraints, personalized care are seldom given to patients.

When Jesus touched the sick, he touched their lives and they became his friends. Remember, the doctor-patient relationship is a contract of trust for care not for a one time meeting.


3. The ultimate goal is not patient well-being.

While medical missions looks into the health condition of the patients, the intent of the mission is not always the person's health. It is an open secret that politicians sponsor medical missions with the real intent of campaigning for people support. Churches sponsor medical missions as an evangelistic tool to persuade people to become Christians. Organizations sponsor medical missions as an outreach activity to gain prestige and recognition. There are other reasons individuals and groups sponsor medical mission but few are intent in addressing the health needs of the people. If the intent is to help people achieve good health, then they know that a one-time medical mission is not enough.

When Jesus came to heal the sick, his purpose was to heal the sick. Remember, health is an end not a means. Lest I be misunderstood, when I say health, I mean the life promised by Jesus in John 10:10.

It is unethical for doctors to violate the principles of medicine. So, like most of my colleagues, I may decline invites in your one-time big time medical missions.

There maybe some benefits to the med missions but we can do better. I can name 5 health ministries churches can do. It is high time we level-up what we can do to improve the health of the community.

Three Reasons Why Doctors are Poorly Compensated

One of the many complains I hear from young doctors is that they are receiving low compensation as APE doctors, reliever doctors and ROD in private hospitals. This is actually not a new issue and not exclusive to a developing country like the Philippines. Doctors oftentimes receive compensation lower than what society expects them to receive. This becomes an ethical issue on justice. I am sharing below the post from theomed.blogspot.com on reasons why physicians are unjustly compensated.

Medical ethics tells us that "(T)he primary objective of the practice of medicine is service to mankind..." This principle has been abused to justify poor compensation for doctors with their work. There is injustice. This is specially true for young doctors who receives retainer fees or compensated for the number of hours rendered. But what is the doctor's service worth? If its value is measured monetarily, how much would it cost?

The first and most common argument thrown is that, "medicine is a service and should not be profit-oriented."

It seems to me that the assumption here is that only those that are cheap and free are considered a service. If you receive good money for a service rendered, that becomes profit-oriented. So doctors are made to believe that it is okay for them to receive little to no compensation for their service rendered. If doctors earn good money for their practice, they are not serving humanity.

This is where the professional fee for the professional service given becomes important. Of course, doctors are either compensated with either retainer fees or fee-for-service. But in general, what is a fair fee for the service rendered by the doctor? What will be a "just compensation" for doctors?
The PMA says the "(P)rofessional fees should be commensurate to the services rendered with due consideration to the patient’s financial status, nature of the case, time consumed and the professional standing and skill of the physician in the community."  They also explained that for self-employed professionals, there is no universal fee. It depends on the prevailing and acceptable fee among the practitioners in the community.

If there is an acceptable fee, why are doctors poorly compensated for their service? Again, this may not be true for fee-for-service doctors with good practice. But this is especially true for many young doctors on retainer fees/per-duty fee or resident physicians.

 

The second reason, doctors are told that the hospital can only afford to compensate them with a small amount for their service. It's either the doctor take it or leave it. Let me illustrate further:

I am looking to hire a helper in our house (pun intended.) She will help cook the food, wash the dishes, clean the house and wash the clothes. I will need her services to have a decent and clean place. For such services, the acceptable rate in our area for helpers is P3000 a month. (Don't ask me where I live.) I can only offer P2000. Although the acceptable rate is P3000, the prevailing rate and the most common rate offered is P2500. Well, times are tough. It's difficult to get a job. I know people need the money. If they don't want P2000 a month, then they don't have to accept it. I am not pressuring them. I am just offering it to whoever is willing to offer their service for that fee. Is it just for me to offer compensation for the service I know is worth more than that? Is it my fault if there are people willing to receive such compensation for their service?

The third and most important reason why doctors are poorly compensated is because NO ONE CARES. Not even the doctors.

 

Maybe because of reason 1 and 2. But this injustice perpetuates because no one is standing against it. A learned prophet once taught, "Learn to do good; seek justice, correct oppression... " (Isaiah 1:17).

 

The injustice must stop. People must do something against the unjust practices. Desmond Tutu famously said, "If you are neutral in situations of injustice, you have chosen the side of the oppressor." We must take sides now. No, one or two person cannot do it.  There needs to be a collective effort to stand against it. The government, the health industry, hospitals, doctors and even patients must do their share. Together, change can happen.

Doctors still do service to humanity. But what is its value to you?

Welcome to Ethics for the Young Doctor

Why this blog?

As I begin to teach bioethics to medical students, I realized there is not too much online material that helps young doctors understand in a simple way complicated matters in bioethics. Not all doctors are bioethicist. But all doctors face ethical issues in their daily practice.

This blog hopes to offer practical insights and opinions on common ethical dilemmas that young doctors encounter in their practice.


To whom is this blog dedicated to?

As I have my students in mind, this blog hopes to be able to communicate to aspiring doctors ethical principles that they need to consider when faced an ethical problem. Medical clerks and interns will be guided on ethical reasoning as they start to be in the clinics. The young doctor will receive insights and opinions as they begin their practice of medicine.


How to read this blog?

The format of this blog is easy and simple. An ethical dilemma will be presented. An ethical question will then be asked. Reflections, insights and tips related to the ethical issue will then be offered. A summary or conclusion will close the post.


What will be the Topics Covered?

This blog will cover a wide range of bioethical issues. Primarily it will discuss:
- Doctor-Patient relationship
- Ethical way to break the diagnosis
- Dealing with sidewalk consults (including consults in SMS, FB, email and phone consults by your relatives and friends)
- Doctor-Pharmaceutical Relationships
- Dealing with RTD and Conference sponsorship from Pharmaceuticals
- Receiving gifts from Medreps
- Doctor-Doctor relationships
- Referring patients to a colleague
- Referral Fees
- Group practice
- Doctor-Society Issues
- Advertising your practice
- Unjust doctor compensation
- Others

What's Next?

The blog offers reflections and insights from the author to help young doctors decide for themselves. It is not an instruction on what they will do. It is, therefore, helpful if readers offer their insights as well to provide alternative views to other readers too. Happy reading and hope to learn from you.