17 Fighting over a case

The Lion, the Bear, and the Fox: A lion and a bear were fighting with each other for the right to devour a little lamb seized by them at the same time. The fight was long and fierce. At the end of it both lay wounded and exhausted. A fox which was watching the scene for long realised that they were too weak to even stand up. He moved in and ran off with the lamb.

A Case grabbing: Seeta, a 30 year old school teacher, consulted a corporate hospital for a neck swelling. An Ear, Nose, Throat specialist diagnosed it to be a thyroid swelling and told her, "It needs to be removed. I can do it. There is no great hurry. Take your time to arrange for your medical leave, etc., and come back within a month or two."

Seeta was apprehensive about an operation and consulted a general surgeon for a second opinion. He examined her and said, "Yes. It is better to operate and remove it without any delay. I can do it next week.” When she informed him about the earlier consultation, he rang up the ENT specialist and they started arguing who should operate on thyroid glands.

Seeta was stunned at this development and left the hospital. She was taken to a plastic surgeon by a health care worker. He managed to convince her that the operation-scar was the most important thing about neck surgery and operated on her.

B Case dumping: Beevi, a 50-year old farm labourer, went to a large teaching hospital as she had not passed urine for three days. The duty physician found that the kidneys were distended with urine and referred her to a urologist. The urologist

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confirmed an obstruction to the urine flow and wanted a gynaecologist to look for pelvic cancer. Pelvic examination revealed cancer of the neck of the womb (cervical cancer). On the question of admitting the case, there was disagreement among them.

The Gynaecologist said: "She has uraemia. It is not our problem now."

The Urologist said: "She has high urea level. It is not our problem now. Lower the urea first."

The Physician said: "How can it be our problem? Unless the obstruction is relieved, the urea will keep mounting."

Beevi was vexed by all this delay and by the way she was prodded and pushed around by the doctors. "Let me go home and die in peace," she thought and left the hospital. The doctors detected her absence much later and recorded on her case file, "case absconded."

Comments

Case-grabbing is a big business now. Health care workers, taxi drivers and others are being employed as touts to fetch cases for surgery and other procedures. These touts can be spotted in and around hospitals offering unsolicited helpful advice to prospective clients. My students, who work in the private sector say, "Cases admitted for surgery are discharged 'against medical advice', transferred to another hospital at night and operated before the daybreak. Disloyal employees are involved in this racket and get a good commission for every case transferred."

If case-grabbing is rampant in private sector hospitals, case-dumping is equally rampant in the public sector hospitals. In USA, over 250,000 emergencies were shifted in a year from 'for profit' hospitals to public hospitals because they could not pay. About one in ten, i.e. 25,000 cases died, mostly due to delay in transit. (Sibbison JB, 1991)

In India, the situation of patient dumping is far worse. Just talk to any patient with a low income and he/she will speak volumes on this. We need effective regulations to curb this practice in public hospitals. The recent release of Citizens Charter of Health Care Rights in Government hospitals is a step in the right direction (see appendix).

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A conscientious doctor, who wants to know if a proposed action is ethical, can apply the following self-test: "Would I like myself or my near and dear to be treated thus?” If the answer is 'no', then the proposed act is unethical.

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