Ethics and making a mockery of the Hippocratic Oath

Reading this case of an unprofessional and unethical doctor in Singapore provided me with some food for thought, particularly around the increasing role of ethics and professionalism, particularly in a world of increasing inequality.

It is critical that the vulnerable segments of society are given the appropriate levels of care and support because where unethical and unprofessional behaviours exist, they tend to exacerbate the suffering upon the vulnerable. Kudos also to the Humanitarian Organisation for Migration Economics (HOME) for pursuing this vigorously on behalf of the victim.

The case itself was interesting. Here was a doctor, Dr. David Wong Him Choon, a noted orthopaedic surgeon at Raffles Hospital, who chose to give only two days of medical leave for a foreign worker who had fractured his hand and had undergone surgery. There is increasing concern that there are doctors who are acting in collusion with construction companies to minimise the time off taken by their workers and to also limit their liabilities for compensation.

What is even more interesting/bizarre, is that previously (between June and December 2015) a Disciplinary Tribunal had acquitted Dr Wong of professional misconduct for giving insufficient hospitalisation leave despite the following findings:

  • The tribunal agreed that the appropriate time off (conservatively) for someone with a distal radius fracture was two weeks of medial leave. (Wong had given two days.)
  • The tribunal also agreed that Wong had failed in his duty to discuss with the patient to understand if there were adequate conditions for his rest and rehabilitation.

Despite the above, the Tribunal chose to acquit Wong on the basis of insufficient proof!

This led the Singapore Medical Council (SMC) (to their great credit) to file an appeal to the High Court which subsequently overturned the tribunal’s acquittal of Wong and convicted him of professional misconduct and sentenced him to suspension of medical practice for a period of six months.

Wong’s behaviour is morally reprehensible and runs counter to the Hippocratic Oath which states: “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”

This raised a few questions for me, namely:

  • What was the composition of the Disciplinary Tribunal that showed such flagrant disregard to evidence, common sense and conventional wisdom and what is their justification for their acquittal of Wong?
  • Whilst Wong has been ordered to pay for the SMC legal and tribunal costs, will Wong also be responsible for the worker’s additional injuries and damages caused as a result of Wong’s unethical and negligent behaviour?
  • Is a six-month suspension/sabbatical a sufficient deterrence? Perhaps in addition to the six-months suspension, there should be a clear statement which suggests he will be struck off permanently for another violation and also be ordered to perform pro-bono activities for migratory workers in Singapore for a period of time. This will be not dissimilar to the Correct Work Orders (CWOs) imposed for a number of other offences in Singapore.
  • In addition to punishment meted out to the doctors, companies and firms, that also are responsible for the prevalence of such despicable practices must also be brought to account and be made an example of.

How a society supports and treats its most vulnerable, its most helpless and its most needy, is an indication of the society’s progress and humanity. A society that is materially wealthy but neglects to look after the concerns of its most helpless is but a poor and miserable one.

 

 

 

 

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The curious (and self-imposed) obstacles in the world of Japanese healthcare

I came across an interesting article in the Wall Street Journal, ‘High Bar for Foreign Nurses in Japan’ (link here)

However, I also wanted to set the context around why this article illustrated some of the really painful self-inflicted punishments the Japanese are currently going through. 

First is the very sad case of a Japanese senior citizen turned away by 25 hospitals in a matter of two hours due to a lack of available doctors, rooms or nurses (story link here) and who subsequently passed away in March this year. 

Next is another very tragic story of a Japanese lady who passed away after 8 hospitals turned her away as she was due to give birth, again citing a lack of doctors or paramedic services. The baby was finally delivered via a caesarean procedure but the mother passed away. This happened a few years back (story link here). There are much more similar and all tragic cases. 

 

This is becoming a common theme in Japan these days. The medical system is strained, there are not enough doctors, there are not enough nurses, there are not enough manned beds, and the ageing population is straining the emergency services, and the situation looks very bleak.

The article I posted at the top of this post however also explains everything that is potentially wrong with Japan’s underlying policies.

Currently there are plenty of foreign nurses (particularly from Indonesia and the Philippines) who are keen to work in Japan and support the creaking medical infrastructure. However, these nurses are put through a very stringent test (7 hours AND in Japanese!) which they have to pass in three attempts or they are sent back home. However, only less than 15% of the foreign nurses who have come into Japan in the last five years have passed the test. 

The article highlights how Japan has around 30 million people over the age of 65 (or just under a quarter of her total population of 127 million). According to the Japanese Health and Welfare Ministry, they estimate that Japan’s population will keep declining by one million every year until Japan has only a population of 87 million in 2060. By this time, over  40% of Japan’s population will be over the age of 65. 

The above demographic trends will place a huge burden on the social welfare system, as well as cause immense strains on the medical infrastructure and severely disrupt Japan’s economic developments. 

There is also a shortage of nurses (estimated to be around 43,000 by the Health Ministry). 

Some of the reasons for this shortage is due to:

  • poor pay (salary is around US$2,500 per month);
  • very bad working conditions and long working hours leading to poor morale;
  • increasing concerns over medical malpractice lawsuits by patients

One would have assumed that this would mean that Japan would take a more pragmatic view to immigration, particularly in the medical sector. However, it is looking very unlikely under current the current premier, Shinzo Abe. ‘Abenomics’ or a combination of economic policies including that of printing of money quantitative easing, weakening of the yen, and good old Keynesian pump-priming of the economy are helping boost (at least temporarily) the Japanese economy. 

There remains however a fundamental problem with the lack of a sufficient number of economically active individuals to support longer term economic growth. Immigration is one tool that can help mitigate this problem but there seems to be a long standing opposition to immigration and there is still a high level of insular behaviour. Tradition and somewhat misplaced views and tendencies (such as attributing crime mainly to a foreigner influx, or blaming foreigners for salaries being cut, and dilution of Japanese culture) still prevail and according to the article , in a national poll conducted in 2012 by the Japan Association for Public Opinion Research, only 1.7% of respondents said that Japan should promote immigration. 

Japan has tried to bring some of the nurses out of retirement but wages remain low which means less of the nurses are keen on coming back. Wages remain low because public debt remains high in Japan and since the government bears the bulk of the medical costs, they are unwilling to raise salaries and wages for those working in health-care. The Japanese Nursing Association estimated that the turnover rate for nurses in 2011 stood at 10.9 percent, indicating that about 150,000 nurses quit that year.

These are extremely serious conditions which Japan needs to tackle.

 

From diversity comes strength. Obscurity will follow insularity.

Japan has to decide which is more important. The preservation of Japan’s culture, the well-being of her people, and the ongoing progress of her economy, may well depend on Japan’s ability to look beyond the status quo and embrace a more pragmatic vision of the future.