“Clean slate for doctors on medical negligence? Are Indian medics incapable of making mistakes? The complete lack of data on cases of medical error seems to indicate as much”, reports Rema Nagarajan in TOI of December 23, 2013.
The starting point to address this malady is to diagnose how frequent and severe is it. With no data on incidence of medical errors and no authority tracking cases of medical negligence, one might be forgiven for imagining that the over 8 lakh (800,000) registered doctors in India are perfect professionals who never make any mistakes, writes Ms Nagarajan. Let us not forget the growing violent actions both in China and India, which have been alluded to in previous blogs, as a desperate attempt in trying to seek justice for the aggrieved.
“Recently, the parliamentary committee on health and family welfare expressed concern over the fact that there is negligible prosecution of medical negligence cases in India. But the committee’s observation draws attention to an even more shocking fact — there is no centralised collection of data on negligence cases filed in India or their outcome”.
State medical councils and the Medical Council of India (MCI) are supposed to maintain registers of all complaints filed against doctors, their status and the outcome of such complaints. But till today, the MCI has not bothered to put together regional data to build a central database for the nation. This means that the magnitude of the problem of medical negligence remains ignored in India notes Ms. Nagarajan.
“All members of the MCI are medical professionals and whenever any complaint of medical negligence or violation of code of ethics is brought before the council, such cases are decided by the medical professionals themselves. There are reports that the medical professionals probing into the allegations of medical negligence are very lenient towards their colleagues guilty of negligence and none of them is willing to testify another Doctor as negligent,” stated the report adding that the impact of this arrangement was that the prosecution in medical negligence cases by the MCI is dismal, highlights the author quoting the parliamentary committee’s recently submitted 73rd report on the Indian Medical Council (Amendment) Bill 2013.
According to People for Better Treatment (PBT), which was started by Dr Kunal Saha (he recently won the record settlement of over Rs 6 crore by the Supreme Court for the death of his wife due to medical negligence), hardly any doctors are found guilty by state medical councils.
For instance, PBT’s RTI enquiry found that just 515 cases were filed against doctors for either medical negligence or ethical violation in one decade (2001-10), barely four cases a month. And action was taken in just 9% — 15 doctors were removed from the council’s list of registered practitioners and 30 let off with a warning. In 91% of cases, either the case was closed or the accused let off, cites Ms Nagarajan.
“State medical councils mostly comprise doctors and most are not even functioning properly. The ones that function do not reveal any data on the complaints or their outcome,” says Dr Amar Jesani, editor, Indian Journal of Medical Ethics. In Maharashtra the medical council was not properly functional for two decades. From 1990 till 2011, it remained mired in controversies regarding malpractices in the election of council members, goes on to highlight the author.
“We had a tough time trying to get data from the different state medical councils. Even with RTI, they give vague information. There is no price to be paid when council members shield doctors in cases that come before them as the public will never know what happens,” says Dr Saha according to the TOI report.
“In other countries, non-doctors like patients and social workers are mandatorily made members of the medical council and they are known as ‘lay members’ and on occasions they may even lead the council as was the case with UK’s General Medical Council,” pointed out the report recommending that the new, revised legislation ought to make it mandatory to have such members on the council. Ms Nagarajan has indeed hit the nail here. Trust all this does not fall on deaf ears.
Not only is this matter begging attention for a fair reporting and corrective actions, we also have a serious issue with rampant quackery and spurious medical qualifications that are a blot on a profession which ought to tread the holy ground with a Hippocratic oath.
Published in Indian Express on December 23, 2013: http://www.indianexpress.com/news/time-for-a-relook-at-insurance-cover-for-corporates-decisionmakers/1210637/0
Published in Journal of Insurance Institute of India, April-June 2013 issue:
Subodh Verma highlights the plight of ‘elderly left vulnerable by government pension ‘pittance’, TOI December 21, 2013.
Ageing, loneliness, healthcare and to top it all the lack of social security now potentially leaves an excess of 100 million Indians outside the safety network of pensions. A staggering number – far in excess of the population of most countries.
According to the report “there are estimated 10 crore persons aged 60 years or above in India as per Census 2011. If you take persons above, the number rises to over 14 crore. In Indian society, the elderly usually depend on their children. Over 30% male elderly and a staggering 72% of women depend on others – usually their children, NSSO 2006 report says. The government runs three pension programmes for the aged, handicapped and widows. The Centre and states together spent Rs 14,370 crore on old age pension in 2011-12; the centre’s share being just 34%. The ministry of rural development says 2.14 crore elderly people get old age pension. That’s just 20% of the total.
The report goes on to say that the Centre gives a ‘princely’ sum of Rs 200 per person while the states have to match it equally. Some, like UP, give only Rs 100 more. Assam adds only Rs 50, Tamil Nadu Rs 600. There are different income and age conditionalities in states. Gujarat has one of the lowest state contribution because it has Rs 24,000 as the maximum annual income for which pension would be given.
In some states, like all the southern, the minimum age is 65 years. Whatever be the case, the average monthly expenditure over the whole 60+ population is an abysmal Rs 124 per capita. The Pension Parishad demands universal monthly pension of Rs 2,000 for all those aged 55 years or above. This would entail a total expenditure of around Rs 2.31 lakh crore. If Rs 500 is given to males over 57 years and females over 55 years, as in Rajasthan, the expenditure would be Rs 27, 688 crores.
“If the government can pay Rs 1.16 lakh crore annually to its retired employees, then surely it should pay Rs 2.3 lakh crore to 14 crore elderly people (55 plus years age)” says Shankar Singh of the Mazdoor Kisan Sangarsh Samiti, one of the constituents of the Pension Parishad.”
The dilemma shall remain but something needs to be done urgently.
In an earlier story I had speculated that managing and breeding cetaceans in captivity may soon come within the purview of HR managers. Whether whales and dolphins will have the benefit of access to the likes of International Human Rights Commission or a separate set of laws and enforcement mechanism need to be codified? But here comes another landmark development relating to chimps – reported by Reuters – bringing them closer to legal recourse hitherto reserved only for the naked ape!
A U.S. animal rights group has recently filed what is supposedly the first lawsuit seeking to establish the “legal personhood” of chimpanzees, report Bernard Vaughan and Daniel Wiessner in Reuters. ” The non-profit Nonhuman Rights Project asked a New York state court to declare a 26-year-old chimp named Tommy “a cognitively complex autonomous legal person with the fundamental legal right not to be imprisoned.”
The lawsuit seeks a declaration that Tommy’s “detention” in a “small, dank, cement cage in a cavernous dark shed” in central New York is unlawful and demands his immediate release to a primate sanctuary. Chimpanzees “possess complex cognitive abilities that are so strictly protected when they’re found in human beings,” Steven Wise, the president of Nonhuman Rights Project, told Reuters.
“There’s no reason why they should not be protected when they’re found in chimpanzees,” he added. The lawsuit on Tommy’s behalf is among three the group is filing this week on behalf of four chimps across New York. The other chimps are Kiko, a 26-year-old chimp living on a private property in Niagara Falls, and Hercules and Leo, two young male chimps used in research at Stony Brook University on Long Island, the group said.
Tommy’s owners, Patrick and Diane Lavery, and Stony university did not immediately return requests for comment. Kiko’s owners could not be reached on Monday. The Nonhuman Rights Project used its own research to find the chimps, and Wise first visited Tommy in October after reading a local newspaper article about exotic animals kept at the Laverys’ used trailer lot in Gloversville, New York, about 50 miles northwest of Albany.
“He looked terrible,” said Wise, who previously observed healthy, wild chimps in Uganda. “Hey looked like a caged chimpanzee – they don’t move, they don’t look at you. They look depressed.” The lawsuit states that chimps are entitled to a “fundamental right to bodily liberty,” which Wise told Reuters is the basic right to be left alone and not held for entertainment or research.
The lawsuit was filed at “the earliest point at which we have some reasonable chance at winning,” said Wise, a well-known animal rights activist and author of books including the 2000 title “Rattling the Cage: Toward Legal Rights for Animals.” “These are the first cases in an open-ended, strategic litigation campaign,” he said. “We’re just going to keep filing suits.”
Nonhuman Rights Project in 2007 began a nationwide search for an optimal venue to file the lawsuits, Wise said. New York was ultimately chosen because of its generally flexible view of requests for a writ of habeas corpus, the centuries-old right in English law to challenge unlawful detention, he said. David Favre, a professor at Michigan State University College of Law and an expert on animal law, said it is the first habeas petition filed on behalf of an animal.
“The focus here is whether a chimpanzee is a ‘person’ that has access to these laws,” said Favre. The lawsuits come as medical authorities re-examine the employment of chimpanzees in research in light of new technology that renders the use of chimpanzees less necessary. In a decision applauded by animal rights groups, the U.S. National Institutes of Health in January said it was reducing its use of chimps in biomedical research, retiring most to sanctuaries. At the time, NIH Director Dr. Francis Collins called chimps “very special animals” that deserve “special consideration.”
Stephen Gandel has recently reported in the Fortune magazine about SEC prosecuting a pair for ripping off the terminally ill, but the “victims” are telling a different story.
‘In mid-September the Securities and Exchange Commission said it had foiled what sounded like the most heinous financial crime since Bernie Madoff’s. A father and son in Lexington, S.C., had run a scheme that, according to SEC, targeted the financially strapped terminally ill, netting the pair $6.5 million from 44 individuals, milking them all the way to the grave. On the day the charges were announced, Kenneth Israel, a regional director at the SEC, said the Stapleses, both named Ben, “turned the misfortune of others into a profit-making enterprise for themselves.” But, bizarrely, others were benefitting from the Stapleses’ scheme – the very people the SEC alleges the pair were ripping off: the terminally ill and their heirs.
The reason the Stapleses could pull off a scheme that seemingly benefits everyone begins with corporate bond offerings and a little-known provision called a survivor’s option. If you buy a bond and die, your heirs are allowed to cash in the bond at face value immediately rather than having to wait until it matures. The survivor’s option is meant for estate planning purposes. On Wall Street some call it a death put. Issuers have used the provision to attract elderly couples – a key debt-buying demographic.
Starting in the mid-2000s, a small group of investors saw another use for death puts: Fissures that would eventually lead to financial crisis were starting to form, causing the price of some normally safe corporate bonds to trade at steep discounts, and the investors began recruiting terminally ill people to buy up the discounted bonds in joint accounts. When terminally ill died, the investors were able to cash in the bonds and turn a quick profit.
Among this group of investors who saw an opportunity in death puts was Ben S. Staples, an accountant. Brenda Eason, 51, said she heard of Staples from a co-worker of hers when her sister, Patricia, 41, was dying of breast cancer in 2011. Eason’s mother had died, and she had to scrape together money to pay for the funeral. Eason’s co-worker said she knew someone who could help her sister, who didn’t have health insurance. Eason and Patricia met Staples and signed up. A few months later another one of Eason’s sisters, Cheryl, 43, was diagnosed with colon cancer. Cheryl signed up with Staples as well. When Patricia and Cheryl died, Eason says that each time she received the $5000 Staples promised, which she used to pay for the funerals. She says she doesn’t see herself or her sisters as victims. “He gave money to people who had nothing at a time we needed it most,” Eason says.’
‘The SEC sees it differently. It appears from the complaint that the SEC’s main beef is that the Stapleses defrauded corporate issuers by saying these were joint accounts, while the SEC claims the terminally ill had no real control over the accounts. In the end, it’s difficult to pin down just who was defrauded.’
London based Duncan Minty has built a solid reputation as an established independent consultant specialising in business ethics, with a particular interest in the insurance and financial planning sectors. Through his expertise, Duncan is able to deliver greater certainty for clients on ethical risks and opportunities, thereby building trust, reduce costs and enhance service.
The specialties he focuses on being: Business Ethics, Insurance, Identifying ethical priorities, Performance measures for ethical issues, Embedding ethics into management systems, Ethics Training Courses, Privacy and Conflicts of interest.
Q: Insurance is a service industry. We do not distribute products, we deliver service. Is distribution to delivery to ethical delivery a logical progression?
A: I see ethics more as a seam running through both distribution and delivery. Get the ethics of your distribution right and the customer is going to be primed and ready for what they’ve really bought, which is good service. This helps the policyholder see the insurer in more of a partnership light and less of a ‘them and us’ one. The ethical ingredient to your service then sets up the relationship for when claims occur, with trust rather than confrontation being the watchword. If you see your business as a suite of different functions, then you’re less likely to see this logical progression. See it as a set of joined up cogs and the progression is clear.
Q: Charity begins at home. First thing first, how does one get this right throughout the hierarchy of an organisation?
A: I think you enshrine it in your company values, then give expression to it as a part of your business plan and finally, but most importantly, you set a clear and unequivocal example. A company that doesn’t include ethical objectives within its business plan can hardly be said to have an ethical culture. There’s also an extra dimension to ‘charity begins at home’, namely that it reminds you not to drop the values and empathy you have for others when you leave for work. Your personal ethics should guide your decisions at work as well as at home. And listening to the concerns of others and showing them respect and leadership can be characteristics of a successful business person just as much as a successful family person.
Q: Insurers deal with multi-channels. Some are captive and some not. How do they bring consistency across the entire spectrum of reach? Many of the partners are outsourced entities like call centres, loss adjusters. They may perform at various levels of ethical behaviour. How does an organisation align them into an overall consistent game plan?
A: Firstly, you need to choose your partners carefully, taking account of how they work to their personal, corporate and professional values just as much as how they charge for this or that service. Ask them to give you some concrete evidence of how they put this into practice, rather than try to work it out for yourself. Then be clear about your expectations of their behaviour when acting on your behalf, showing what is acceptable and what is not. So for example, if you want adjusters making your claims decision to never use information obtained by illegal or unclear means, then write that into the loss adjusting service agreement, with penalties to match. In essence, it’s all about transparency, accountability and consistency.
Q: It is about getting both the physics and chemistry right. You may have a great structure and process – how do you get it right at the feeling level? Is it about fool-proof embedding?
A: Having someone at the top of the company who sets the right ethical example and encourages others to follow his/her lead helps a lot. Get those two things right and more likely than not, you’ll end up with a corporate culture that encourages openness and discussion. When people then feel they have a voice in your firm, and will be listened to, you get a lot more understanding and accountability.
Look at this from the other way round: the danger with closed cultures is that the chemistry can sometimes become rather active and blow up when no one realises it!
I think that fool-proofing embedding comes from being very clear about “walking the talk” on values and ethics: making sure that they’re actively used in decision making, even when it may result in business being lost. People realise the firm is serious about ethics and adapts their personal behaviour to match it.
Q: How does an ethical conduct of delivery impact overall governance within an organisation and vice-versa?
A: It’s clear now that if those overseeing the governance of insurance delivery in the UK over the last 20 years had paid more attention to the rights and wrongs of what they were doing, then the sector would have a much better reputation and be better off to the tune of many, many millions of pounds of compensation. Those in governance have a tendency to focus on internal controls and procedures, and to fail to stand back enough and consider the ethics of how products were being used by distributors. Then they would recognise that how products are designed and priced has an influence on how ethically they’re likely to be delivered, something that the itemised thinking behind a lot of governance can’t spot. That said, fusing together governance thinking and ethics thinking can work in those markets with a more ‘rules based’ approach to insurance regulation, the US being one such instance. The UK now has a more principles based approach and insurers are trying to adopt accordingly.
Q: Does ethical conduct tantamount to treating customer more than fairly?
A: I don’t see it that way, for no other reason than that would imply that treating someone fairly was less than ethical. Fairness is a key part of ethical conduct, yet fairness also has more than one dimension, so is often misunderstood. This is evident at the moment in the UK with regard to the provision of flood insurance. I think fairness is a good theme for customers to connect with (better with a fairly technical term like ethics) and if you embue your overall delivery strategy with fairness, that goes a long way to satisfying many customers. Remember though – you can’t deliver one type of fairness to one set of customers and another type of fairness to another set of customers. So yes, follow the ideas behind fairness, but keep it balanced.
Q: Can there be shades of ethical conduct? Moving from distribution to delivery to ethical delivery – is it evolutionary or revolutionary?
A: I don’t think there are shades of ethical conduct per se, but I do think that ethical conduct can be a journey rather than a destination, and a journey with the odd bump and wrong turning along the way. So the shades come in more around how far you are along that journey and the extent to which your ethical road is bumpy or unclear. The business world is always in some state of flux and coping with what it throws up is always going to be presenting your firm with ethical challenges. That is healthy, for it keeps us on our ethical toes and reflecting on what we are doing. The firm who says it’s got its ethics all sorted out and dealt with is, I fear, a firm that is failing to reflect on what is going on around it and adjusting accordingly.
I think that a firm’s ethical journey can be evolutionary at times and revolutionary at times, depending on what it is experiencing in its business sector. I think that insurance claims in the UK is about to undergo an ethical revolution – the clever insurers will be those who anticipate the need for revolutionary change and take those steps now themselves, rather than be forced to in the way required by the regulator.
What needs to be remembered about evolutionary change is that it may be relatively slow and long term, but it is extremely powerful and ruthless, with the weakest dying away and those most tuned to their environment adapting and thriving. The survivors recognise what is going on around them, tune in to it and adapt to the necessary conditions of survival. Evolution is not a soft option.
Q: How do you audit & ascertain ethical consistency?
A: I think that examining a firm’s ethical culture will illuminate a lot about its ethical consistency. The essence of this approach is to look at what the firm says, then at what the firm does and then at where (and why) the two are different. The findings can be both surprising and exciting, as they can unearth some hidden truths (at least hidden to the firm, not necessarily to its customers!) and show some long term infuences that are still making an impact. You can expect to hear more about ethical culture as issues about how insurance claims have been handled in the UK are exposed by regulators here.
Q: Is it ethical to treat ethical as a differentiator?
A: It certainly is, for your customers have the right to know they can put more trust in your firm and as a result choose to buy your products more often. This differentiates your firm in the market and earns you reputational and financial rewards.
That said, you shouldn’t act ethically just in order to differentiate your firm. Differentiation on ethics is an outcome of being ethical and shouldn’t be its raison d’etre in the first place. Think of it this way: if you act on your values and ‘do the right thing’ only when it is profitable to do so, then it hardly seems right to give up your values when it happens to become less profitable.
Q: How important is ethical delivery for emerging markets? Are there any learnings from the more developed ones?
A: Ethical delivery is just as important for emerging markets as it is for the more established markets. That’s because the same mix of customers, providers, intermediaries, suppliers and regulators are present in both. There’s no case to be made for customers in emerging markets expecting anything less than customers in the more established markets.
It is however unfortunate that a lot of what can be learnt from the more developed markets are the type of ethical shortcomings that need to be avoided: I’m thinking of mis-selling in particular. Emerging markets are well positioned to see how to avoid repetitions of such scandals – it’s down to regulators, professional organisations and insurance leaders to emphasise just how important it is to steer clear of such misdeeds.
Are there more positive things to be learnt, other than simply how to avoid the mistakes? To a degree, yes. Emerging markets can test out some of the processes that have helped firms in more established market achieve better ethical outcomes, but they must do so with a clear agenda to adapt them to their own market’s circumstances. A key part of developing an ethical capacity is learning not what others have decided are the answers, but the process by which to ask the right questions of yourselves and how to implement the answers that come out of that.
To many tennis enthusiasts, of this generation, Jimmy Connors may be a distant memory. He was one of my heroes. I never saw him play. What I interestingly saw was his restaurant “Centre Court” in the small town of Belleville, Illinois. Now face to face with his book “The Outsider”, wherein Jimmy also highlights some amazing insights about his formidable mom and I cannot wait to share till I am done with this entire lovely memoir. Perhaps there will be more as I progress with it. Men can be very mean when it comes to success of women. I do not wish to come in the way of what champion Jimmy has to say in his words:
“A lot has been written about my mom being a stage mother, so let me set the record straight. Why was it OK for Joe Montana’s dad to teach his son football or Wayne Gretzky’s dad to teach him hockey but it wasn’t OK for Gloria Connors to teach her son tennis? Mom stepped right into a man’s world and a man’s game during the height of Women’s Movement in the 1970s. Up until that point, people weren’t used to dealing with a woman in the business end of tennis; both men and women players had men as managers, and men organized and ran tournaments. Along comes this feisty little woman from East St. Louis whose son was proving to be a winner, and they had to deal with her. While Billie Jean King was in the forefront as the first woman athlete to enter the boardroom, Mom had already been doing exactly that behind the scenes, fighting the established tennis bureaucracy. Now, if I hadn’t been winning, they could have dismissed her and it wouldn’t have been a big deal. But my mom represented me. And not only represented me but was my mother, coach, and friend.
She paid the price for treading into that traditionally male-dominated territory by having some pretty aggressive criticism thrown at her by the tennis establishment and the media. They would say she wanted my success more than I did because she had never had it herself, that she hadn’t been good enough so she tried to make her son good enough. They called her “domineering” and “Dragon Lady.” If it got to her, I never knew about it and neither did anyone else.”
A Countermeasure Research on Doctor – Patient Disputes and Medical Malpractice Insurance – Aspects of Local Policies and Regulations:
I finally have an English transcript of this paper presented at the 2013 China International Conference on Insurance and Risk Management, Kunming. The paper is co-authored by Li Zhongmin, Board Member of China Willis Insurance Brokers, Kunming; Tao Yin an Associate Chief Physician; Xu Wenjuan an Assistant Lecturer and Duan Xiaohua of Yunnan Chinese Medical School. It marks early days but for sure represents a very diverse collaborative approach to address a very serious societal challenge.
“Abstract: As China’s public health affairs are undergoing reform and transformation, medical disputes are occurring more and more frequently and have become a serious social problem. According to statistics by China’s public health authorities, from 2000 to 2010, 148 major malignant cases related to medical disputes occurred nation-wide, ten murders merely in 2011. During the three-month period August to November 2010, as per the Public Health department of Yunnan, 765 medical disputes were reported by 2706 medical organizations in the province. With 150 unrests and 43 group disturbances which caused financial loss worth four million Yuan. “
“On March 23, 2012 a hospital attack happened at the First Affiliated Hospital of Harbin Medical University, leaving three hospital staff injured and one dead. The doctor hatred sentiment was aroused again”, according to this paper. ”The attack is a wake-up call for governmental and regulatory authorities. What can we learn from such a lesson? What is the fundamental cause for the situation? What do the medical system design, legal protection, administrative regulation and financial compensation lack? All these questions require serious consideration and contemplation from us and we can only find feasible solutions from the reality.
Therefore, the paper explores the problem from different angles: how to deepen systematic reform and improve operational mechanics, how to make policy and regulations and create positive legal environment from the top. And how to tackle the risk by combining legal, administrative and economic measures all together.
The paper provides suggestions on product development of medical compulsory insurance and commercial insurance. When a unified regulatory standard of medical malpractice is impossible to be imposed nation-wide at this moment, it becomes especially important and urgent for governmental authorities of different layers and local regulations to make action and play a full role in medical practice control and regulation. The paper aims to provide innovative ideas and practical examples in search of feasible solutions of the problem, which is also the difficulty facing this paper.”
It is indeed impressive to see some very fundamental questions being asked and addressed by a cross section of specialties – Insurance being one of them. The answers may not be at hand but the fact that all concerned have gotten together as the world of tort unfolds itself in the Chinese Mainland – solutions will emerge. It is this mainstreaming of insurance profession and discipline that the Indian market needs to also draw inspiration from as stray cases of attacks on hospitals keep getting reported. Perhaps a single regulator can tie all the loose knots far more effectively than what a plethora of control points would!
The Diversity Blog 