I believe that there was always corruption in the medical and scientific fields. It however only became truly visible during the COVID-19 pandemic. However we need to do some work to root out why it came about and when it came about. So we are going to do a little time travelling to discover the reasons for all this avarice and deceit.
Transparency International, a watchdog on these matters, defines corruption as the abuse of entrusted power for private gain, which in healthcare encompasses bribery of regulators and medical professionals, manipulation of information on drug trials, diversion of medicines and supplies,…
It doesn’t take a rocket scientist to figure out why corruption arises. All you have to go back to an age old idiom “money is the root of all evil.” Where there is great wealth to be had, great corruption is soon to follow. I think I just coined a new phrase. It did not show up on the internet. There is no denying that there is a lot of money in the modern pharmaceutical industry.
Epistemic Corruption, the Pharmaceutical Industry, and the Body of Medical Science
When a knowledge system importantly loses integrity, ceasing to provide the kinds of trusted knowledge expected of it, we can label this epistemic corruption. Epistemic corruption often occurs because the system has been co-opted for interests at odds with some of the central goals thought to lie behind it. There is now abundant evidence that the involvement of pharmaceutical companies corrupts medical science. Within the medical community, this is generally assumed to be the result of conflicts of interest. However, some important ways that the industry corrupts are not captured well by standard analyses in terms of conflicts of interest. It is not just that there is a body of medical science perverted by industry largesse. Instead, much of the corruption of medical science via the pharmaceutical industry happens through grafting activities: Pharmaceutical companies do their own research and smoothly integrate it with medical science, taking advantage of the legitimacy of the latter.
Introduction: Epistemic Corruption
“Corrupt” and its cognates are old terms with many metaphorical uses. Bodies, fruits and meats are corrupted when they begin to rot, decompose, or otherwise spoil. What is thought pure is corrupted when mixed with something foul or lesser, as when air is made foul by pestilence or smoke, noble lineages are supposedly lessened by poor marriages, or people become less good simply because of the pressures of society. “Each of us is born with a share of purity, predestined to be corrupted by our commerce with mankind, by that sin against solitude”.
It is only a small step from the introduction of pollution to the perversion of ends, as when a public official is corrupted by money or power for a purpose, to serve some interests rather than others. This is the most familiar kind of corruption today—so common that the metaphor has largely died—in which corrupted office holders and institutions have been captured by outside interests, or perhaps serve only their own interests. Thus there is a United Nations Convention against Corruption, which never needs to explicitly define “corruption,” though it identifies it as involving a constellation of crimes that include bribery, embezzlement, influence peddling, illicit enrichment, etc.
There can be value in analyzing knowledge systems in terms of all the above and other senses of the metaphor. When a knowledge system importantly loses integrity, ceasing to provide the kinds of trusted knowledge expected of it, or even in some cases when it ceases to establish trust, we can label this epistemic corruption. For example, the weaknesses of mathematical models can become entrenched, especially if they are constantly adjusted through curve-fitting, as has been claimed about several epidemiological models of the spread of Covid-19. Or, environmental toxicology may systematically lack information about the risks of a large number of industrial and agricultural chemicals, because powerful entities can control private science and shape public science. And, outside the sciences, although many accusations of “fake news” are wide of the mark, large swaths of both social and traditional media are genuinely untrustworthy, whether because of interests that shape the creation or the dissemination of news, or because of inherent weaknesses of systems designed to capture audiences’ attention.
My focus here is on how the pharmaceutical industry corrupts medical science. Using its very substantial resources, pharmaceutical companies co-opt medical knowledge systems for their particular interests, interests that conflict with the integrity and at least some of the central goals thought to lie behind medicine. It would seem that the body of medical science is corrupted because some assumed purity—though purity is always notional—has been affected by contact with outside interests.
Pharmaceutical Industry Affects Medical Research
For the past 25 years, researchers have been studying the effects of industry funding—most often from pharmaceutical companies—on medical science. One typical protocol compares outcomes in industry-funded and other clinical trials in some therapeutic area, or for some class of drugs or medical devices, working either from searches of the published literature or from some other sample, such as conference abstracts. Most reports of clinical trials declare sources of funding, so analysts can often cleanly divide publications and make comparisons. In addition, clinical trials within areas often have enough uniformity that at meta-analyses can sometimes be done. Since the mid-1990s, there have been hundreds of published studies of industry influence, comparing many thousands of clinical trials across all domains of medicine. The researchers designing and following these protocols often frame them as analogous to medical studies, with industry funding being the intervention, and the integrity and stability of the body of medical research being the outcome.
A 2017 Cochrane Review provides a meta-analysis of such studies of industry funding, in which 75 studies, comparing more than 8,000 trials, met inclusion criteria. In all of its dimensions, the 2017 meta-analysis arrives at the same or similar results as had earlier quantitative and qualitative reviews. In the meta-analysis, industry funding had a risk ratio of 1.27 of producing favorable efficacy results, and of 1.34 of drawing favorable overall conclusions. Since there is no reason to think that non-industry funding skews results in any consistent direction, one can only conclude that industry funding biases the outcomes of clinical trials. Put simply, if a pharmaceutical company funds a trial, the chances of results and conclusions in that company’s favor are increased. However, in this study, industry and non-industry research did not differ on such standard methodological quality concerns as sequence generation, allocation concealment, follow-up, or selective outcome reporting; and industry sponsored studies even had better blinding procedures.
The authors of the Cochrane Review conclude: “Our analyses suggest the existence of an industry bias that cannot be explained by standard ‘Risk of bias’ assessments”. When pharmaceutical and other companies sponsor research there is a bias—a systematic tendency toward results serving their interests—but the bias is not seen in the formal factors routinely associated with low-quality science. The implication is that industry funding itself should be considered a standard “risk of bias” factor in clinical trials, one that is quantifiable, and even quantified, and pushes in predictable directions. Industry funding affects the results of clinical trials.
But Funding is Rarely just Funding
The Cochrane Review I have just described shows that the pharmaceutical industry corruption of medical science doesn’t happen through the mechanisms currently assessed by typical formal methodological measures. Funding itself corrupts medical science. But this does not mean that it is mysterious.
The most common way of understanding corruption through funding is in terms of conflict of interest. Perhaps funding and payments to researchers create conflicts of interest, which—for conscious or unconscious reasons—affect their actions, their judgments, and their conclusions. As a result, these conflicted researchers become more likely to report outcomes friendly to their funders. However, something else is at play here as well, and it is this that I want to illustrate below.
There is abundant evidence that conflicts of interest are important in many domains, including across medicine. For example, financial conflicts on committees producing clinical practice guidelines tend to produce assessments of evidence and recommendations that favor the companies and industries involved. In terms of medical practice, a recent systematic review shows that payments to physicians influence prescribing. The broad issue of conflict of interest is important enough that the United States Institute of Medicine issued a detailed report on it, overwhelmingly about how financial conflicts involving industry affect researchers’ and physicians’ judgment. Despite such evidence, a focus on conflict of interest hides how pharmaceutical companies influence published results and outcomes.
Funding is rarely just funding. Most pharmaceutical company-sponsored clinical trials are designed, organized, audited, analyzed, and written up by the companies and their hired subcontractors. This is all work that happens behind the scenes, obscured by the form of academic publication. Thus much of the corruption can happen through more substantive medical choices and through structures of influence and control, as I describe below.
Roughly 70–75% of the industry’s expenditures on clinical trials go to contract research organizations (CROs), rather than to independent researchers in the form of grants. CROs together have revenue estimated to be approximately US$50 billion in 2020, most of it coming from pharmaceutical industry clinical trials. As a result, in the comparison of “industry-sponsored” and independent research, in most cases the “sponsorship” involves direct control over the research.
Even when it appears that industry-sponsored trials are led by academic or other actors, and that their subjects are recruited via independent clinics, hospitals and academic medical centers, it is most likely that at a higher level they are run by CROs working for pharmaceutical companies, and analyzed by company statisticians and others. Manuscripts are most likely drafted by ghostwriters on structures created by publication planners, and then shepherded through to publication by those planners, with limited opportunities for their academic and other independent authors to contribute. The published articles, then, are largely creations of the companies, even if the nominal authors include independent researchers. All of this constitutes the “ghost-management” of medical research.
The ghost-management of trials affords many opportunities to intervene on individual publications and to affect the published record, producing the effects of industry sponsorship I described above. I list some significant categories, for each of which I provide an example or evidence.
(a) Companies can design studies that are likely to produce favorable results, making careful choices of comparators, doses, experimental populations, surrogate endpoints, trial durations, and definitions. For example, in Merck’s testing of its COX-2 inhibitor rofecoxib, it used most of these techniques to improve one or another of its published trials.
(b) Given the ghost-management of industry-funded research, funding almost certainly affects the interpretation of data and the writing of articles. Internal company documents and presentations show that the companies are fully aware of the opportunities for spin.
(c) Sometimes the corruption goes so far as to count as scientific misconduct, such as direct manipulation of data, omission of adverse events, etc. On the basis of documents from litigation against Forest Laboratories for misleading marketing of citalopram, establish conclusively that the ghost-management of the research allowed company employees to publish efficacy and safety conclusions that were inconsistent with what the trial data could support.
(d) Industry trials with positive results are over-represented in the medical journals, and those with negative results are under-represented, resulting in significant publication biases. In antidepressant trials submitted to regulatory agencies such as the United States Food and Drug Administration or the Swedish regulatory agency—and thus all industry trials—positive results are much more likely to be published. The positive trials are often multiply published by lumping and splitting, than are those with negative results. This has produced an impression in the medical literature that the evidence for the effectiveness of antidepressants is much stronger than it actually is.
(e) Industry trials are more cited than are non-industry trials. This may be because when publication planners assign a manuscript to a ghostwriter, it appears that a list of references is frequently one of the key inputs, and companies have good marketing reasons to cite themselves. However, the higher level of citation may be simply a result of the fact that pharmaceutical companies have much better resources for promoting their own trials than individual researchers have. For example, the companies employ thousands upon thousands of “key opinion leaders” to give talks to physicians, using prepared slide shows, on recent clinical research.
The pharmaceutical industry corrupts medical science and the medical literature through these mechanisms and many more. In the ghost-management of research, much of the corruption does not happen via traditionally conceived conflicts of interest of independent medical researchers. Instead, it happens by more direct actions by drug companies and their agents, such as those listed in (a) to (e) above.
Discussion: The Body of Medical Science
While it initially seems likely that medical science is corrupted by medical researchers’ conflicts of interest, that picture doesn’t capture at least some of what is going on. Instead, pharmaceutical companies create their own research and its own ways of disseminating that research, relying on structures and traditions of medical science to legitimate their work. While we could talk of companies as having conflicts of interest, it is more natural to talk of them as acting in their own interests.
In the pharmaceutical companies’ ghost-management of research, much of the corruption of medical science happens through a process of grafting. Grafts on plants make two bodies into one, typically allowing a fruiting part of a plant of value—to the horticulturist—to thrive by drawing on nutrients provided by a different plant’s rootstock. Grafting involves a carefully constructed parasitic relationship. Similarly, pharmaceutical companies add substantially to medical science, doing their own research, smoothly attaching it to medical science in a way that integrates it, and then nurturing it to make it predominate. Non-industry medical science provides legitimacy to the apparently similar additions. The effects of industry sponsorship of medical research are the results of prominent additions to the body of medical science, not the simple introduction of an element—such as funding—that infects what it touches.
Of course, the pharmaceutical industry is a huge one, and in some areas of medicine the grafts permeate or overwhelm everything else in the area. And it is likely that the grafts affect the bodies onto which they are grafted: industry science may, for example, create costly research norms that in turn create demand for more industry funding.
Like most systems that can be corrupted, medical science has never been pure or perfect. But the pharmaceutical industry can trade on the presumed innocence of medical research’s overriding goal: creating knowledge to benefit patient health. That is, some standard narratives of medical research attribute to it purity of heart, and a mere shortage of means that can be rectified by industry support.
In a very different context, Kierkegaard writes: “As the world changes, the forms of corruption also gradually become more cunning, more difficult to point out.” In its corruption of medical science, the pharmaceutical industry has borne this out.
CORRUPTION IN HEALTHCARE AND MEDICINE
Corruption in healthcare and medicine: Why should physicians and bioethicists care and what should they do?
Corruption, an undeniable reality in the health sector, is arguably the most serious ethical crisis in medicine today. However, it remains poorly addressed in scholarly journals and by professional associations of physicians and bioethicists. This article provides an overview of the forms and dynamics of corruption in healthcare as well as its, implications in health and medicine. Corruption traps millions of people in poverty, perpetuates the existing inequalities in income and health, drains the available resources undermines people’s access to healthcare, increases the costs of patient care and, by setting up a vicious cycle, contributes to ill health and suffering. No public health program can succeed in a setting in which scarce resources are siphoned off, depriving the disadvantaged and poor of essential healthcare. Quality care cannot be provided by a healthcare delivery system in which kickbacks and bribery are a part of life. The medical profession, historically considered a noble one, and the bioethics community cannot evade their moral responsibility in the face of this sordid reality. There is a need to engage in public discussions and take a stand – against unethical and corrupt practices in healthcare and medicine – for the sake of the individual’s well-being as well as for social good.
Corruption is, to say the least, a complex phenomenon and a difficult problem. It is complex because of its deep roots in the social, cultural, economic, political, legal, and ethical value systems of individuals, communities, cultures, and countries. It is a difficult problem because it defies easy answers and resists any single-track, copy-book model of solutions.
There was a period in the not-so-distant past when corruption was considered, at best, merely an issue of development and, at worst, a socioeconomic issue beyond the world of scientific medicine. In the recent past, however, corruption in the health sector has raised serious concern and received global attention among researchers and policy-makers. In October 2003, the UN General Assembly adopted the United Nations Convention against Corruption, which came into force in 2005. Other UN agencies have also undertaken anti-corruption measures in health. For example, the Good Governance for Medicines program, launched as part of the World Health Organization Medicines Strategy, 2004-2007, incorporated corruption as a priority issue. Further, having recognized the relationship between child mortality and corruption, the United Nations Children’s Fund linked its promotion of child rights to good governance.
Undermining the moral vision—and nobility—of the art of healing, corruption is arguably the most serious ethical crisis in medicine today. Thus, understanding corruption, its varied nature and its adverse effects on health outcomes is absolutely necessary for healthcare professionals in the 21st century, not only to steer clear of fraud, but also to devise effective strategies to tackle the menace and safeguard the moral vision of medicine.
What is corruption?
Corruption has been defined as “the abuse of public office for private gain”. This definition appears to be narrow as it does not cover areas other than “public office.” Transparency International, a global anti-corruption watchdog, defines corruption as “the abuse of entrusted power for private gain”. Questions may arise about how terms such as “private” are defined and whether it would be ethically justifiable to abuse entrusted power for shared collective gain. Private gain may also be either actual or potential, and financial or even political. It is thus extremely difficult, if not impossible, to provide a definition of corruption which is applicable to all its forms, types and degrees across various cultures to the satisfaction of all stakeholders. In the absence of such an all inclusive and precise definition, “the abuse of entrusted power for private gain” may serve as a ‘working definition’ as it could cover, in general, most of the unethical and corrupt practices in the health sector.
Corruption is pervasive across cultures and endemic in countries, be they small or large, poor or rich, capitalist or socialist or in the North or South. Newspapers generally capture only startling instances of large-scale corruption. Petty corruption, however, has long been a part of, or rather a way of, ‘normal’ life in many parts of the globe. Furthermore, those who take or give bribes in a particular setting may claim in another setting that these were ‘gifts’. Thus, cultural interpretations and legal implications of what is perceived of as corruption may also vary from one context to another.
What are the forms of corruption in healthcare and medicine?
The problem of corruption in healthcare is of a multidimensional nature. Corruption may be involved, for example, in construction of health centers/hospitals, purchase of instruments, supply of medicines and goods, overbilling in insurance claims and even appointment of healthcare professionals. Another aspect of the problem is the involvement of multiple parties, e.g. policy-makers, ministers, economists, engineers, contractors, suppliers, and doctors. All this may give rise to innumerable clandestine transactions of a corrupt nature among various stakeholders.
Forms of corruption in healthcare and medicine may include, but not be limited to, the following:
Bribes and kickbacks
Characterized as hallmarks of corruption, bribes and kickbacks can be paid by individuals and firms to procure government contracts, leases or licenses for the construction of healthcare facilities, and for the supply of medicines, goods and services, as well as ensure the terms of their contracts; prefix and ‘rig’ the bidding process; manipulate and falsify records, and modify ‘evidence’ to give the appearance of its being in compliance with the norms of regulatory agencies; speed up the procedure of permission to carry out legal activities, eg obtaining institutional affiliation, company registration or construction permits; and influence or change legal outcomes so as to avoid punishment for wrong-doing.
Theft and embezzlement
This may occur as theft of public assets and goods, such as instruments and medicines, by individuals for sale, personal use or use in for-profit private clinics. The theft of government revenues, such as patient registration fees, and the payment of salary to deceased or “ghost” workers are other forms of corruption.
Intentional damage to public goods for private gain
Public assets and instruments in government hospitals may also be intentionally damaged so as to make them unavailable to patients, with the ultimate aim of ordering the services from private clinics in return for financial incentives or “commission.”
Perceived somewhat less often as a form of corruption, absenteeism (not attending work but claiming salary) in the health sector has been a major concern in some developing countries.
In some countries, patients commonly make informal payments to healthcare professionals for better services. The imposition of such a “tax” on “free” healthcare services has a negative impact on access to health services.
Use of human subjects for financial gain
Clinical researchers get paid by the biomedical industry for the recruitment of poor and illiterate, ie vulnerable, human subjects for clinical trials. Another way in which hospitals and physicians use patients is by charging uninsured patients and patients with other health plans far more than the actual costs involved and what the health insurers pay.
Institutionalized potential corruption
In some for-profit hospitals, physicians have contractual obligations to admit a fixed number of patients to allotted beds and prescribe a number of laboratory investigations (even if unnecessary) to generate revenues.
Whatever the form, corruption has far-reaching consequences on patient care, clinical research and medical education..
Case studies: windows into how corruption affects health sector
Published reports on the exploitation of human subjects in clinical trials and the scam in the National Rural Health Mission (NRHM) in Uttar Pradesh (UP), India, give us a window into how unethical and corrupt practices can mar clinical research and public health programs, turning them, quite literally, into “killing fields”.
Few would disagree that clinical trials hold the promise of making a positive difference in the lives of people. However, there is no room for such a pleasant illusion in the face of the unethical and corrupt practices in health research. Nearly 2900 people died in India during clinical trials of drugs conducted by various pharmaceutical companies from 2005-12, and compensation was paid in only 45 cases. This news came after an earlier news report that victims of the 1984 Bhopal gas tragedy were also enrolled, without their knowledge or consent, in clinical trials sponsored by certain pharmaceutical companies. Further, as revealed in 2008, 49 babies had died during clinical trials for new drugs at the All India Institute of Medical Sciences, India’s premier medical institution, over a period of two-and-a-half years.
|Primary areas||Specific aspects under primary areas||Types of unethical and corrupt practices||Implications|
|Patient care||Construction of healthcare facilities||Bribes and kickbacks for procuring contracts, speeding up procedure||High cost, low-quality construction work and facilities that do not fulfil needs, resulting in inequity in access|
|Purchase and supply of medicines, goods and services||Bribes, kickbacks to fix winner of bids in advance|
Unethical marketing and sales of medicines
Suppliers not held accountable for failing to deliver
|High-cost, sub-standard or inappropriate drugs and goods and equipment|
|Distribution and use of medicines||Sale of “free” drugs or supplies|
Theft of drugs/supplies at storage and distribution points_
|Undue “tax” on free drugs and supplies|
Lack of access to essential medicines for poor patients
Interruption of or incomplete treatment of patients
|Access to healthcare, admission into hospital||Bribes and informal payments||Lack of access to basic healthcare for poor patients|
|Monitoring and regulation of quality in products, services||Bribes for approval of registration and quality of drugs|
Bribes or political considerations influencing results of inspections or suppressing findings
|Circulation of counterfeit or fake drugs in market|
Spread of infectious and communicable diseases
Death of patients from improper treatment or inadequate services
|Biomedical research||Clinical trials||Recruitment of human subjects for drug research for financial incentives|
Absence of adequate compensation policy for participants in trials in case of
injury or death
|Exploitation of “guinea pigs in human form” in unethical trials|
Death of trial participants without compensation
|Students’ research||Bribes or informal payments for “supervising” students’ research projects||Fraud and misconduct in research and publication|
|Medical education*||Admission||Bribes to gain entry into medical education|
Political influence, nepotism in selection of students
|Entry of incompetent healthcare professionals into medicine|
Loss of faith, cynicism and frustration with an unfair system
Ethically compromised professionals who perpetuate the vicious cycle of unethical and corrupt practices
|Examination||Bribes to pass qualifying examinations or top merit list|
|Appointment of physicians and medical teachers||Nepotism, favouritism, political influence in selection of healthcare professionals|
|Note:*The head of the Medical Council of India, removed from his post for allegedly taking bribes to grant permission for the establishment of private medical colleges, was president-elect of the World Medical Association (WMA).|
Perhaps this is the price for putting economics before ethics. In 2005, as a policy pursuant to economic liberalization, the Government of India amended Schedule Y of the Drugs and Cosmetics Act to permit concurrent phase II and phase III trials in India. A myriad of factors, such as substantial reduction in time and cost in conducting clinical trials, diverse population, English-speaking healthcare professionals and less stringent regulatory mechanisms, made India one of the most attractive locations of clinical trials. Not surprisingly, there was a substantial growth in the number of clinical trials held in India from 2005. In 2000, the Indian Council of Medical Research (ICMR) had issued ethical guidelines for biomedical research on human subjects (modified in 2006) and the registration of clinical trials was made mandatory by the Drugs Controller General of India (DGCI) in 2009. However, the ICMR guidelines are not legally binding, while the DCGI is understaffed and ill-equipped to monitor and regulate research effectively. Thus, blatant unethical practices, such as providing lucrative financial incentives for the recruitment of human subjects, obtaining “informed-but-not-understood-consent” from poor illiterate “volunteers,” and failing to provide compensation for the death of participants in trials, have become a part of the booming industry of clinical trials in India.
Part of the threat that the industry of clinical trials poses to India stems from the fact that these trials, conducted mostly by the contract research organizations (CROs) hired by pharmaceutical companies, are essentially commercial ventures in the garb of benevolent medical research. The question arises as to whether the drugs tested in India will actually benefit or be affordable for needy patients. The crisis is further compounded by the dampening “ethical climate” of the Indian institutions that are related to the conduct of clinical drug trials. India ranks 94th in the list of 178 countries in the corruption perception index . In a country where corruption is undeniably an all-pervasive part of life, including healthcare and medicine, it is hard to imagine that if at some point, provisions are made for ethical oversight of all clinical research, such oversight will be of the highest standards and that “guinea pigs in human form” will get high-quality care in keeping with ethical standards. Questions thus arise whether it is ethically justifiable to allow the conduct of clinical trials to begin with, in the absence of ethical oversight, effective regulatory mechanisms and an appropriate compensation policy for the participants, especially in countries plagued by corruption.
National Rural Health Mission, Uttar Pradesh
In 2005, India launched a centrally-funded country-wide health program, the NRHM, in order to revamp rural health. The Government of India allocated the state of Uttar Pradesh (UP), which can rival sub-Saharan Africa in terms of infant mortality and child malnutrition, “the largest sum of money of all states” to improve the abysmal status of its health services.
What went wrong with the NRHM in this state?
- According to the report of India’s Comptroller and Auditor General (CAG), the UP State Health Mission failed to fulfil its mandate and was responsible for an unaccounted loss of Rs 5754 crore out of the total amount of Rs 8657 crore.
- “[I]n the case of NRHM in Uttar Pradesh, it was organized looting of government funds.”
- According to the Central Bureau of Investigation (CBI), “Large-scale bungling took place in the implementation of NRHM. The modus operandi for siphoning off state wealth included overpricing, fake supply of medicines and hospital equipment by fictitious firms as well as huge kickbacks in construction activity to improve health services in government-run primary health centers in rural areas. The CBI also discovered how some persons acted as middlemen between contractors and influential bureaucrats and ministers to supply medicines and equipment under the program”.
How did people suffer when the NRHM was beset by corruption?
Subhadra Chaurasia developed cataract in her right eye four years ago. In the past one year, visibility in her left eye has also faded. If the 75-year-old doesn’t receive medical attention soon, she will go completely blind. She has two sons, both married, who barely make a living from the 2.5 bighas [of land] they own in Raipur village, 10 km away from Lucknow. The yield from this landholding is just enough to save the family from starvation. With no money to buy even basic necessities of everyday life, Subhadra can’t dream of having an eye operation, something that would cost more than Rs 15,000. But if you go by official records, Subhadra has already been operated upon and cured.
NGOs, private nursing homes and doctors have siphoned off crores of taxpayers’ money intended for eye operations for the rural poor in the state over the past five years.
Tehelka [investigative journalists’ team] visited more than half a dozen villages in and around Lucknow and found that the women, children and men who should have been the beneficiaries of the NRHM funds are living without the most basic health services. The funds meant for them have been siphoned off by the politician-bureaucrat-private contractor nexus.
NRHM’s Mothers Protection Scheme, known as Janani Suraksha Yojana, was launched in 2005 to provide conditional cash transfers to pregnant women for facilities like transportation to encourage them to give birth in health facilities. But civil society organizations find pregnant rural women didn’t receive quality maternal health services, especially if they were from lower income groups….
Quality of care in UP is poor, according to nongovernmental organisations, and may have worsened due to the corruption.
Crores of rupees were thus spent on the construction of nonexistent healthcare facilities, and on the acquisition of goods and services which never reached the intended beneficiaries. This scam not only perpetuated ill health and suffering among the rural poor, but also cost six lives. Among the six persons who died are top-ranking medical officers, murdered presumably as part of a cover-up operation to hush up the wrongdoing.
What is fearsome is that it is only the tip of the iceberg which is visible; the bottom of the “iceberg” of corruption is almost untraceable. Sadly, the art of healing has turned into a science of stealing and the conspiracy to cover up has introduced criminality into medicine. What is scandalous is that doctors are not only among the victims of corruption; they are also beneficiaries and perpetrators, together with the others involved in the larger nexus that is threatening to undermine the very foundation of medicine. The question arises as to what physicians and bioethicists should do to tackle the menace of corruption and to answer this, one must be clear on why they should do something in the first place.
Medical corruption: why should physicians and bioethicists care?
There are a number of good reasons why physicians and bioethicists should care about corruption, discuss the problems that corruption creates and perpetuates in healthcare and medicine, explore possible remedial measures to tackle the menace, and take a stand against unethical and corrupt practices in the health sector.
The first is, to put it simply, corruption kills. The difference between life and death, good health and suffering is often determined by corruption. Not surprisingly, the poor suffer the most. Three of the UN’s eight Millennium Development Goals, which are intended to reduce poverty by half by 2015, relate directly to health: reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases.
Corruption in the healthcare system has been revealed as one of the factors responsible for the failure to fulfil these goals by the target date. Corruption also exacerbates the harm caused by natural disasters. For example, the death toll in the earthquake in Haiti was directly related to corruption. Buildings certified as earthquake-resistant had not been constructed properly because the system was plagued by corruption and thus, there was a lack of oversight. If physicians are really opposed to serving the machinery of death, oiled by corrupt practices in medicine, they need to address the issue, discuss it and take a stand against it.
The second is that corruption fosters ill health and prolongs suffering. On the other hand, good governance (reduced corruption) is associated with better health outcomes. A transnational study found that the quality of governance was positively associated with higher life expectancy, lower mortality rates for children and mothers, and higher levels of subjective feelings of health. By taking a stand against corruption and in favor of appropriate anti-corruption measures, healthcare professionals may create opportunities for good governance and consequently, better health outcomes for the population.
Thirdly, corruption undermines the patient’s trust in the physician and healthcare delivery system. Trust lies at the core of the doctor-patient relationship in medicine. “Trust is critical to patients’ willingness to seek care, reveal sensitive information, submit to treatment, and follow physicians’ recommendations.”. Patients would not like to see a doctor they do not trust and would be loath to accept such a doctor’s advice. By taking a stand on corruption, physicians and bioethicists can start rebuilding the trust of patients and the people at large.
The fourth is that corruption destroys the moral vision of medicine. Ethics lies at the heart of medicine-it is difficult to imagine a good but corrupt physician. Few would disagree that medicine sans morality turns this praxis into one of stealing, killing and criminality. Those who have embraced a noble profession like medicine cannot afford the luxury of “doing nothing” when its ethical foundation is being endangered by unethical and corrupt practices .
Towards a new beginning: what should physicians and bioethicists do to tackle the menace of corruption?
Corruption in the health sector is not just an issue of development, or a legal issue pertaining to fraud and abuse, but also an issue concerning ethics. As darkness is characterized by lack of light, corruption is characterized by a lack of moral values. Regrettably, the word “corruption” is conspicuous by its near absence in the agenda and vocabulary of academic medicine. At most, mention is made of “professional misconduct.” Worse still is the deafening silence of the medical profession when the cause of ethics in medicine is at stake. Furthermore, bioethicists, who are the modern-day custodians of morality in medicine, have little, if any, interest in addressing this “dull” social problem. Unlike esoteric ethical puzzles such as determining the moral status of a part-human part-animal embryo, this problem does not trigger enough hair-splitting debates to satisfy their philosophical minds. The initiation of proactive measures to counter corruption in all its manifestations is long overdue. A number of anti-corruption measures that could provide a starting point are outlined below.
- Zero tolerance for unethical and corrupt practices in health
- Whole-hearted support for anti-corruption measures
- Protection of whistle-blowers
It is time to acknowledge that corruption in healthcare entails crimes against humanity. There is no room for complacency- history will not forgive physicians and bioethicists if they fail in their moral duty to safeguard the cause of ethics in medicine when it is necessary.