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G20438 STATES
UNITED
World Medical
Journal
Official Journal of the World Medical Association, INC Nr. 1, February 2011 vol. 57
• Medical Ethics and Personal vs. Public Conscience
• Tobacco-Free World in Twenty Years’ Time!
• Czech Medical Chambers’ Experience to Make an Agreement
wmj 1 2011 5CS.indd I 21.02.2011 16:27:19Cover picture from Korea
World Medical Association Officers, Chairpersons and Officials
Dr. Wonchat SUBHACHATURAS Dr. Dana HANSON Dr. José Luiz Dr. Edward HILL
WMA President WMA Immediate Past-President GOMES DO AMARAL WMA Chairperson of Council
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Sao Paulo, SP
Brazil
Dr. Masami ISHII Prof. Dr. Jörg-Dietrich HOPPE Dr. Torunn JANBU Dr. Otmar KLOIBER
WMA Vice-Chairman of Council WMA Treasurer WMA Chairperson of the Medical WMA Secretary General
Japan Medical Assn Bundesärztekammer Ethics Committee 13 chemin du Levant
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Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
ii
wmj 1 2011 5CS.indd Sec1:ii 21.02.2011 16:27:44Interested in Global Health? Join the World Medical
Association – Become an Associate Member
For over 60 Years the World Medical And although many physicians know WMA
Association has been the global platform policies and hopefully many more know the
for medical ethics, physician affairs and WMA, only a few are aware that individual
international medicine. It has been and is physicians can be Associate Members of the
being driven by the national medical asso- Association. With a very affordable rate the
ciations being the constituents of the or- membership in the WMA is not a matter of
ganization. Outstanding physicians have money, but of engagement. Our Associate
been and are until today its leaders. With Members stand for an independent medical
currently more than 90 nations in our profession. Together we strive to achieve the
Association we are a truly global medical highest possible standards of medical care,
voice representing more than 9 million ethics, education and health-related human
physicians worldwide. rights for all people.
Among the achievements of the World Associate Members have access to all work-
Medical Association are landmark docu- ing documents of the Association and
ments like the first International Code of they are invited to voice their opinion on
Medical Ethics (1948), the Declaration our policy making either by writing or by
of Geneva often referred to as the mod- Otmar Kloiber participating in the Association Members’
ern Hippocratic Oath (1949), or the most Meeting. The yearly Associate Members’
famous of our declarations the Declaration of Helsinki – Ethi- Meeting can even send its own policy proposals to the General As-
cal Principles for Medical Research Involving Human Subjects sembly for consideration. Membership benefits also include a sub-
(1964) – to mention just 3 out of more than 100 policies on medi- scription to the World Medical Journal and significant discounts
cal ethics, human rights and socio-medical affairs. All of them are on our registration fees for the WMA General Assembly and the
living documents, up-to date, not trendy, but value- and reality- interim Council Session.
based. They guide physicians all over the world in difficult ethical
situations, from the bedside at hospitals to the battlefields of this More information and the possibility to sign up can be found on
world. Our policies have proven value and receive the highest re- our website www.wma.net.
spect.
For the people of this world health is bridge to peace and a better living.
The World Medical Association is the voice of the physicians at
the international organization like the United Nations, the World We are building it. Please join us.
Health Organization, the International Labour Organization, Dr. Otmar Kloiber,
UNESCO and many others. WMA Secretary General
1
wmj 1 2011 5CS.indd 1 21.02.2011 16:27:45Medical Ethics MALAYSIA
Following his article, Fish was roundly
Medical Ethics and Personal vs. criticized for being half-right in his inter-
pretation of conflicting conscience, but in-
Public Conscience: a Malaysian Context tellectual disagreement continues to divide
mostly implacable and partisan ethicists.
In Fish’s article, he underscored an earlier Nancy Berlinger in an ensuing Hastings
statement by Mike Leavitt, Bush’s Secre- Center Report [2] has this to say: ‘Stanley
tary of Health and Human Services, who Fish… recognizes that defining “conscience”
had said that, “Doctors and other health more loosely – as “moral intuition,” or those
providers should not be forced to choose “secret thoughts”… does not solve our contem-
between good professional standing and porary problem. When medical professionals be-
violating their conscience.” The direction lieve that they are being forced to do harm or are
of the Bush doctrine was of course to urge prevented from doing good, the ethical solution
the conservative right against unfettered may not always be the conscience-clause remedy
abortion on demand, which continues to of stepping away from troubling situations.’
divide the American people.
Where does this leave the medical pro-
Professor Fish reviewed the etymology of fessional when it comes to ethical under-
“conscience” as ascribed to English phi- pinnings of doing what’s right or wrong?
losopher Thomas Hobbes. Here one of the Would our personal conscience suffice? Or,
earliest definitions of conscience, referred to should we subsume to the greater wisdom
those occasions “when two or more men know of our collective professional voice (e.g.
David KL Quek of one and the same fact ... which is as much national medical associations, professional
to know it together,” and where, violation of bodies, world medical association, medi-
Some time ago, New York Times colum- conscience meant that knowing together, cal councils, etc.), which through the long
nist Professor Stanley Fish (NY Times 12 men prefer their “secret thoughts” to what arduous passage of time and historical ex-
April 2009) [1] wrote about “Conscience has been publicly established. periences, would have honed a burnished
vs. Conscience”, where he discussed the if straitjacketed version of what’s generally
conundrum about how people in general Fish acknowledged that Hobbes understood accepted as “ethically and publicly correct”?
and physicians in particular, under different that many consider conscience to be the name
circumstances should or shouldn’t abide by of the private arbiter of right and wrong. Be that as it may, does this mean that the
their own conscience. But Hobbes regards this as a corrupted us- medical professional would then have no
age invented by those who wished to elevate need to rely on his own personal conscience
The contending issue was that physicians “their own ... opinions” to the status of reliable and moral standing? No, but surely if these
should not refuse treatment or procedures knowledge and try to do so by giving “their are diametrically opposed to the greater
based on their own personal moral or religious opinions ... that reverenced name of Conscience.” wisdom of peers, then one has to justify
grounds. Professor Fish argued that there one’s personal convictions all the more!
is such a thing as a collective “public con- Hobbes’s main argument is that if one can
science” which should supersede that of one’s prefer one’s own internal judgments to the Again, this cannot be taken out of context
personal conscience and value systems, no judgments of authorized external bodies of the prevailing society and sociopolitical
matter how entrenched these may have been. (legislatures, courts, professional associa- situation. This becomes extremely relevant
tions), the result will be the undermining in societies such as in Malaysia and other
During the Bush administration, the culpa- of public order and the substitution of per- quasi-democratic nations, where govern-
ble clause, called the Provider Refusal Rule, sonal whim for general decorum: “... because ments tend to be paternalistic, even ar-
allows health care providers to refuse to par- the Law is the public Conscience ... in such di- rogant or worse [3]. The instruments and
ticipate in procedures they find objection- versity as there is of private Consciences, which institutions of power are often abused to
able for moral or religious reasons. The main are but private opinions, the Commonwealth forcefully interpret laws or even medical
bone of contention was of course regarding must needs be distracted, and no man dare to findings in a slanted manner, which severely
freedom to choose abortion, pro-choice, or obey the Sovereign Power farther than it shall test the mettle and autonomy of physicians
conversely, pro-life. seem good in his own eyes.” under their charge.
2
wmj 1 2011 5CS.indd 2 21.02.2011 16:27:48MALAYSIA Medical Ethics
In certain authoritative or political circum- Sadly some of these dubious practices place the doctrine of public conscience and uni-
stances, the medical professional is called us at odds with the perceived wisdom and versal principles rather than personal ones,
upon to exercise extreme judgment calls, conventions of some greater external collec- when carrying out our duties, including
which can be sorely tested by either threats tive conscience. These conventions although when making judgment or pronouncement
from or fears of authority (e.g. police, su- seemingly unenforceable, have long been on some of our possibly errant colleagues.
perior officers, military, even political pow- articulated by world authorities such as the Sectarian perceptions whether religious or
ers) or worse, direct or indirect “rewards” for World Medical Association and even the political, clearly must take a back seat, and
passive compliance! United Nations Human Rights Commission. should not be allowed to color our thinking
or decision making.
The 1st century AD Hindu code, Charaka The UN High Commission for Human
Samhita [4], exhorts doctors to “endeavor Rights Istanbul Protocol [9] is categorical in Personal bias or experience or even con-
for the relief of patients with all thy heart stating that: viction should yield to the more nuanced,
and soul; thou shall not desert or injure thy perhaps more balanced decision based on
patient for the sake of thy life or living”, “Dilemmas arising from these dual obligations strict interpretations of statutes, codes of
which have been restated in many codes are particularly acute for health professionals professional conduct, and perhaps legal
of professional conduct including our own. working with the police, military, other securi- precedents.
Yet, these are often pushed to the backburn- ty services or in the prison system. The interests
er, when conflicts of duties, arise. of their employer and their non-medical col- The US Supreme Court [10] has ruled that
leagues may be in conflict with the best interests when the personal imperatives of one’s re-
Recent in Malaysia, public spats on medical of the detainee patients. Such health profes- ligion or morality lead to actions in viola-
testimonials and reports have arguably cast sionals with dual obligations, owe a primary tion of generally applicable laws – laws not
long shadows as to the so-called impartial- duty to the patient to promote that person’s best promulgated with the intention of affront-
ity, ethics or professionalism of some of our interests and a general duty to society to ensure ing anyone’s conscience – the violations will
medical colleagues [5]. Forensic pathologists that justice is done and violations of human not be allowed and will certainly not be cel-
are facing some intense scrutiny of late, due to rights prevented. Whatever the circumstances ebrated; because: “To permit this would be to
questionable lapses, incoherent practices and of their employment, all health professionals make the professed doctrines of religious belief
perhaps even perceived selective memories, owe a fundamental duty to care for the people superior to the law of the land, and in effect
and slipshod standards of duty of care [6]. they are asked to examine or treat. They cannot to permit every citizen to become a law unto
be obliged by contractual or other considerations himself.” Therefore, we must be quite clear to
Other physicians making medical reports to compromise their professional independence. dissect conscionably our dilemma of which
are also put under the microscope for their They must make an unbiased assessment of the is the superior right.
perceived biasness or slant of their reports, patient’s health interests and act accordingly.”
one way or the other, until the truthfulness Similarly, in the context of political or au-
of one vs. the other, appears difficult or im- Unfortunately, this protection by conven- thoritarian pressure, especially where dem-
possible to discover [7]! tion appears so remote to the lonely phy- ocratic institutions are weak, and where
sician standing in the grips of perceived risk to the individual may seem likely, it
Such ambiguous if disingenuous medical authoritarian powers, whose influence are behooves the professional to be reminded
findings or reports cast a dismal if disap- imaginably all-powerful! about the World Medical Association’s Dec-
pointing view on our profession [8].While laration of Geneva [11], which is a modern
some of these appear coerced, some might Seen in this context, society must exert its restatement of the Hippocratic values, as
conceivably be simply venal, just as if medi- moral imperative of the public good on a well as to be cognizant of UN Conventions
cal veracity can be made to sway according universal basis, and demand the application such as the Istanbul Protocol. Doctors are
to the purchasing power of the most damn- of such universal conventions, to protect the reminded that the health of their patients
ing and powerful! hapless physician at the centre of such po- is their primary consideration and that we
litical or partisan storms, lest such pressure must devote ourselves to the service of hu-
Physicians must be reminded that for that lead to further erosion of already debilitated manity with conscience and dignity.
patient (deceased or detainee) under his/her institutions.
charge, there is frequently no other person We must learn and adhere to our historical
whose interests can be represented, except Similarly, the onus is on members of the memories, that which are collectively ac-
from the physician’s unbiased assessment… medical profession to remain steadfast to knowledged as “correct” and first and fore-
3
wmj 1 2011 5CS.indd 3 21.02.2011 16:27:49E-health AUSTRALIA
most for our patients’ interests. Certainly, in Thus, personal conscience and public con- 6. Quek DKL. Ethics, medical confidentiality vs.
this context, every professional should not science must be employed together to shape political pressures. Malaysiakini, July 31, 2008.
let religious, political or sectarian reasons our moral compass when we are dealing http://dq-liberte.blogspot.com/2008/07/eth-
ics-medical-confidentiality-vs.html
from influencing our decision-making. with ethics and medical professionalism. It
7. Chong D. Teoh family disappointed with Brit-
helps when we all undertake to reexamine ish pathologist’s report. Malaysian Insider 26
But does this mean that these are fixtures our own values and learn more and more as April 2010. http://www.themalaysianinsider.
which cannot or should not be modified to how these ethical dilemmas and ques- com/index.php/malaysia/61368-teoh-family-
with the passage of time and perhaps move tions are evolving in this day and age. We disappointed-with-british-pathologists-report.
in tandem with the “fashion” or faddism of must not be cowed into a mindset of conve- 8. Quek DKL. Physicians must be more vigilant.
current perceptions or even societal move- nient way out or of callous expediency [12]. Malaysiakini, March 11, 2009. http://myhealth-
matters.blogspot.com/2009/03/doctors-must-
ment or direction?
be-vigilant-when-dealing.html.
9. Istanbul Protocol. Manual on the effective in-
Clearly this will depend on the circum- References vestigation and documentation of torture and
stances and the human aspects of all pa- other cruel, inhuman or degrading treatment or
tient-physician interactions. Although eth- 1. Fish S. Opinionator. Conscience vs. Conscience. punishment. Office of the United Nations high
The New York Times. The Opinion pages. 12
ics these days are not as immovable or as commissioner for human rights. United Na-
April, 2009. http://opinionator.blogs.nytimes.
permanently cast in stone, societal views do tions, Geneva, 1999.
com/2009/04/12/conscience-vs-conscience.
evolve. Like sometimes shifting tides, ethi- 10. Scalia J. Opinion of the Court. Supreme Court
2. Berlinger N. Conscience: We’re not donne yet.
of the United States; 494 U.S. 872. Employment
cal perceptions may very gradually ebb and Bioethics forum. The Hastings center report. 7
Division, Department of Human Resources of
flow, but often with the anchored moorings May 2009. http://www.thehastingscenter.org/
Oregon v. Smith. Certiorari to the Supreme
and underpinnings of moral public good Bioethicsforum/Post.aspx?id=3404&blogid
Court of Oregon No. 88–1213 Argued: Nov. 6,
=140.
and greater and greater foundation of uni- 1989; Decided: April 17, 1990.
3. Quek D.K.L. Unbiased treatment for all.
versal values. Malaysiakini, March 23, 2010. http://myhealth-
11. WMA Declaration of Geneva. Revised 173rd
Council Session,Divonne-les-Bains,France,May
matters.blogspot.com/search?q=ethics+
So changes may occur, but again these must conscience. 2006. http://www.wma.net/en/30publications/
4. Roy P, Gupta H. Charaka Samhita. A scien- 10policies/g1/index.html.
be based on contextual interpretation which
tific synopsis. 2nd ed., Indian National Science 12. Quek DKL. A New Malaysia still possible.
should be carefully justified so that the Malaysiakini, March 9, 2010. http://dq-liberte.
Academy, New Delhi, India, 1980.
newer interpretation can withstand scrutiny blogspot.com/2010/03/malaysiakini-new-malay-
5. Quek DKL. Kugan’s Autopsy Findings & In-
and/or rigorous re-examination, by an in- quiry: Unsettling Questions remain. Malaysia- sia-still.html.
creasingly knowledgeable public and also by kini, April 8, 2009. http://myhealth-matters.
even more discerning generations of similar blogspot.com/2009/04/kugans-autopsy-find- Dr. David KL Quek, President,
professionals. ings-inquiry.html. Malaysian Medical Association
Clinicians Driving Change:
Supporting Patient Care
Speech at the E-health conference 2010, Melbourne, 30th November 2010
The promise of e-health has been on the record shows how close we really are. I would
horizon for many years. like to acknowledge the efforts of Dr. Muke-
sh Haikerwal in pushing the e-health agen-
While the full potential of that promise is da. In his charming way, he has been tireless
yet to be delivered, it feels like we are just a and determined in bringing together all of
little bit closer to making e-health a reality. the relevant players over the last few years.
The very fact that we are here today discuss-
ing the practical steps we need to develop His involvement has had a significant im-
the personally controlled electronic health pact on the e-health agenda and its progress. Steve Hambleton
4
wmj 1 2011 5CS.indd 4 21.02.2011 16:27:54AUSTRALIA E-health
Doctors are excited about the prospect of doctors don’t always have all the clinical in- on three different pathology computers. A
sharing patient information electronically formation that we need to provide the saf- CT scan of the abdomen and an ultrasound
with each other and with other health care est, most clinically appropriate care. of the abdomen were also needed to make
providers to improve patient safety and the the diagnosis.The patient had no way of
quality of care we provide. This is where information obtained by other recalling the sort of detail that I needed to
health practitioners in relation to my pa- make the diagnosis, or even of being sure
Many GPs now hold accurate and compre- tient during other episodes of health care what tests had been done.
hensive information about their patients could ensure that I don’t miss the critical
that has been progressively built up over issues that could impact on my treatment For example, the negative cardiac enzyme
more than a decade. decisions. tests were just as important. I was the only
one who had all of the information avail-
But at present the only way we can share it Here is a “live” example from one of my pa- able. The diagnosis would have been made
is by printing it.Even then, it may or may tients last week.John told me that he had much more quickly if we all had all the de-
not be with the patient when he or she ar- a number of times called an ambulance to tail in “real time”. It was time consuming
rives at the next doctor – and even then, at his home because he had severe abdominal for me and inconvenient for the patient –
best it is subject to transcription errors. pain – RUQ 10/10.On the first two occa- maybe even life threatening.
sions, his pain had gone by the time the am-
Today I am going to talk about what my bulance arrived, and he was not transported. This is just one example where the sharing
medical colleagues think must be done to He had a health summary from me with him of a patient’s information between health
get the first stages of the electronic health detailing his cardiac history, his diabetes, his care providers could make a real difference
record up and running, and ensure that it is AAA, his past history of cholecystectomy. to the quality, safety, and cost of the health
done in a way that will best assist doctors in He also had retained gallstones in the bile care that I could deliver.
caring for their patients. duct after the above surgery and needed
an ERCP and sphincterotomy to solve the At the most basic level, doctors should be
We need to strike a balance between clini- problem.The next three times he was taken able to access from electronic health records
cal safety and consumer expectations in the to Royal Brisbane Hospital Emergency important information such as:
design and use of the electronic health re- Department where, once again, they were • pathology results;
cord. To succeed, the e-health record must in possession of his paper history. The pain • diagnostic imaging results;
be easy to use, support what doctors already invariably went away within a few hours of • discharge summaries; and
do, and not disturb time-honoured clinical arriving at hospital.His diabetes and vascu- • current medications and adverse events.
methods.We doctors talk to our patients, lar disease were proving to be a distraction.
take a history, perform a medical examina- The CT Abdomen showed nothing more This is basic information, yet critical to pa-
tion, assess supporting information, order than his AAA, and the US of the liver was tient care.
investigations if needed, then make a diag- normal.This information trickled in to me
nosis for the patient and decide on a treat- some days after his hospital visits.The first When I talk to doctors, and when I think
ment plan. discharge letter contained the blood results, about my own practice, I am struck again
which showed a rise in his liver function and again by what a difference it would
That is the hard part about what we do. It tests that were consistent with obstruction make – even in the case I have mentioned –
takes years to learn and even longer to get of the bile duct.The second and third letters if we had an electronic health record.
good at it. If doctors can rapidly access rel- from A&E did not include the above but,
evant data via the electronic health record, it when I asked for them to be faxed, it was The record could facilitate the sharing of
will support this process. But irrelevant data clear that on each occasion that there was this most basic yet critical patient infor-
will get in the way. acute pain the liver enzymes rose. mation between treating doctors and other
health providers.
During my consultations with my patients, For the non-doctors in the room, it was
I find that most of them have a reasonable clear evidence of bile duct obstruction.This It would deliver a very loud bang for the
understanding of their health circumstanc- was enough evidence to convince another buck. Clearly, I am talking about a very
es – and they are usually very honest with gastroenterologist that he needed another small but fundamental part of the much
me about what’s going on with them. But ERCP and, sure enough, there were two grander plan for a personally controlled
commonly – despite our best intentions – more gallstones.There were five blood tests electronic health record.
5
wmj 1 2011 5CS.indd 5 21.02.2011 16:27:55E-health AUSTRALIA
Let’s start with the basics and get it up The AMA supports the premise that the This is also the point at which I think the
and running. Let’s start with electronically sharing of accurate summary patient infor- personally controlled aspect of the record
shared patient summary information that mation between treating doctors is critical is very relevant. A personally controlled
cannot be altered by the patient, and which to the success of e-health. record that patients would operate along-
is accessible to all doctors. side the summary information shared by
This is information that sits beside a per- doctors could prove to be a great motivator
I am not suggesting that the personally sonally controlled record. It is essential that for many patients to become more involved
controlled aspects of the electronic health this record contains reliable and relevant in their own health care. In my experience,
record are not important. The point I am medical information about individuals. when my patients take responsibility for
making is that, if we are to get take-up of It is important that it aligns with clinical their health and work with me, we usually
the electronic health record by doctors, the workflows. It must integrate with existing get the best outcomes. Most doctors don’t
doctors need to be able to trust the reliabil- medical practice software. Otherwise we are like “Dr Google” and there are good reasons
ity and accuracy of the information the re- faced once again with the transcription er- for that. But it is undeniable that the advent
cord contains so that they can act on it. rors I spoke of earlier. It is also very impor- of the Internet has produced patients who
tant that the personally controlled record are more informed and perhaps a bit more
Most patients would recognise the need for has appropriate security measures to protect prepared when they come to see me.
treating doctors to be confident about the patient privacy.
information that they have before them. I actually prefer it when patients with ongo-
I can’t think of any of my patients who We believe that if the system is to be truly ing health concerns take an active interest
would object to me being able to have ac- national and consistent, it must be governed in informing themselves about their con-
cess to information about where they have by a single national entity. ditions and in actively engaging with me
recently been hospitalised, or when they about the steps they can take to manage
needed to see another doctor. In fact, many We believe governments must fund the sys- their condition better.
are surprised when I don’t have that kind tem and support its take-up with appropri-
of information at my fingertips already. ate incentives, education and training. I think there are generational issues here
How many patients have turned up at their with some patients older than me who are
GP before the specialist’s letter or before Progress in these areas would provide bene- reluctant to use the web all that much. I find
the discharge summary has arrived?In fact, fits to patients through efficient and accurate that patients about my age are quite will-
the Menzies-Nous Australian Health Sur- communication between GPs, other special- ing to go after information and to inform
vey published last week found that: “Most ists, hospitals, and other health providers. themselves.
people believed their doctor and all the people
treating them should have direct access to their Over time, once the initial capability to Now there are young people who can’t
health record.” share the summary patient information stop pulling down information. The chal-
across healthcare settings is rolled out, there lenge with them is to direct their gaze to
The AMA has thought very hard about how is significantly more information that could useful locations and to stop them getting
doctors will integrate the personally con- go on the summary. sidetracked. I think that the personally con-
trolled electronic health record into the way trolled record will encourage and empower
they practise medicine. At the AMA, we It could include information such as pros- patients to take more responsibility for as-
are talking about the sharing of summary theses, implants, ECGs, referrals, advance pects of their health care. The opportunity
patient information electronically between care directives, health care plans, and team to create their own record about how they
treating doctors. care arrangements to name but a few. are managing their health will help patients
to keep track of their conditions and medi-
We don’t talk about sharing all of our pa- Clearly, as the information on the record cal history. This should dovetail into home
tient information – just the key informa- starts to get more complex, patients will monitoring for things like diabetes and
tion that other doctors need to provide safe, inevitably and very reasonably want more blood pressure.
quality patient care.And that is what we rules around who can access all that extra
do already – when I refer my patient to a information. This, in turn, will lead to patients being able
specialist, I don’t send their entire file. I just to truly engage with their health care pro-
send the key information that I think the Privacy of and access to those parts of the vider to provide better management of their
specialist needs. record will be very important. health.
6
wmj 1 2011 5CS.indd 6 21.02.2011 16:27:57AUSTRALIA E-health
However, we need to strike the right bal- Unfortunately, if patients have the ability to electronic health record will entirely remove
ance here between the health care provider’s remove or “make private” facts that are part the need for patients to tell their history to
need to provide safe patient care and con- of their summary information, they might every new health professional they see. But
sumer expectations about the role of the in- do so – for all kinds of reasons. And if they it will streamline it.
formation they control in the record when choose to do so, then the record may be-
health care is delivered to them. comes useless to a doctor because the doctor Doctors and other health providers who are
could never rely on it. committed to safe, quality patient care will
It is not realistic to expect that doctors will need to have that conversation and practise
turn to information put in the personally For example, when prescribing medication, their craft, no matter what is in the record.
controlled record by the patient as the de- if the anti-depressant was hidden, the real
finitive source of information on which to possibility of a serious adverse medication As I said earlier, it is essential that doctors
base clinical decisions. Doctors will always interaction could exist. If Tramadol is pre- can rely on the summary information in-
take a history, do an examination, and scribed, then it could precipitate a serotonin cluding:
make an assessment and diagnosis putting syndrome if the patient was taking an SSRI • pathology results;
different weights on different types of in- (Selective serotonin reuptake inhibitor). • diagnostic imaging results;
formation. We cannot just rely on what is • discharge summaries; and
in the personally controlled record. Often, Once the personally controlled record is • current medications and adverse events.
diagnoses or previous conclusions need to up and running, if there is just one serious
be challenged. Just like my patient I men- adverse medication event like this, then e- As we develop the personally controlled
tioned earlier. I have never ever seen a pa- health will not have delivered on its promise. electronic health record, we need to con-
tient with retained gallstones after ERCP sider that e-health in primary care will
and sphincterotomy, but that is what the If the summary information was not avail- drive most of the health system benefits.
evidence said. To get it right we need all able to the treating doctor, then the whole
the evidence though. Even now, doctors venture will have failed. Those benefits will be most apparent in
have concerns that patients might be re- the acute care setting. Most of the costs,
luctant to share some information with Failed the patient. Failed the doctor. Failed however, will be incurred in the primary
them. Patients may think that once in- the health system. care setting.
formation is on the record – somewhere,
sometime – that information might be ac- The summary patient information needs to With this in mind, the Government must
cessed inappropriately. Patients are already be accessible to all doctors. invest in e-health at the primary care level
concerned about how treatment decisions or the momentum will stall. The right ap-
might affect them in other aspects of their It should only be able to be changed by proach, the right information, and the right
lives. doctors who understand the implication of investment in e-health can deliver real ben-
what is recorded – and this can certainly be efits to patient care and to the efficiency of
I recently saw a patient who wasn’t sure done in consultation with the patient. the health care system.
whether he wanted to be prescribed anti-
depressant medication for fear that some- Conversely, the addition of some informa- The AMA and the medical profession stand
how down the line it could “get out” and tion into the electronic record by a patient ready to get behind e-health and make it
affect his employment as a teacher. These could also pose a clinical risk – if the doctor the reality that the Australian health system
kinds of concerns will become even more were to rely upon it. needs.
important to patients when diagnoses,
treatment decisions, and medications are For instance, many patients believe they Dr. Steve Hambleton, Australian
shared electronically. have allergies to drugs, but they are simply Medical Association, Vice President
side effects. While they are important, they
So, if we look at a world where there is a do not have the same clinical impact. For
personally controlled electronic health re- example, Augmentin nausea, muscle aches
cord – where information may be in “The with statins.
Cloud” and therefore truly accessible – it is
entirely understandable that those concerns If we think about these examples, it is clear-
for patients will intensify. ly not true that the personally controlled
7
wmj 1 2011 5CS.indd 7 21.02.2011 16:27:58Medical ethics UNITED STATES
headed a commission that proved the link
Humbled by Those Who Crossed between yellow fever and mosquitoes
• The North African battlefields of World
Bridge of No Return War II were also a battleground that
proved the miracle of antibiotics
daily basis. When they were finally released, • During World War II, the work of Navy
they walked to freedom across that Bridge Captain, Robert Phillips, broke new
of No Return. ground in the treatment of cholera
Overall, the Pueblo’s commander and crew Trauma and disaster medicine also have
were in pretty bad shape physically. All had military roots:
lost weight, and there were skin diseases, • Medical triage first took place on Napole-
jaundice, pneumonia, infections, contu- on’s battlefields, offering a way to deal
sions, abrasions and broken bones. Despite with casualties and save lives in an orderly
their ill health and having been tortured, way
the Pueblo crew walked across that bridge • In the late 1940s, military physicians did
united, loyal and upbeat. None had been co- pioneering work in the treatment of burn
opted by the North Koreans. They had not victims
turned on one another. • As a result of casualties in the Middle
Eastern conflicts we have seen new treat-
In their forced confession they had man- ments for amputees and advances in pros-
aged to send a message of their own to the thetic technologies
Cecil B. Wilson American authorities. Their spirit could • Out of Vietnam came an understanding
have been destroyed, but it was not. Today, of the importance of the “golden hour”
Lately I’ve been thinking about bridges. the behavior of the Pueblo crew during that and the need for early, even pre-hospital,
One bridge in particular has been in my captivity is held up as model of prisoner-of- treatment. Our civilian EMT and mede-
mind: the so-called Bridge of No Return war resistance. vac systems are a direct result
between North and South Korea. • The Vietnam War and more recent mili-
I have always felt privileged – and sad- tary conflicts in the Middle East taught
Here’s the story. More than 40 years ago, dened – that I was on hand to meet these the value of a systems approach to han-
as a young naval medical officer, I was part men and their commander after they came dling mass casualties – a lesson civilian
of the team that examined crew members across that bridge and were brought to the medical teams applied after the 9/11 at-
of the USS Pueblo after they were released Balboa Naval Hospital in San Diego. It is tacks, the 2004 tsunami, Hurricane Ka-
from captivity in North Korea. The Pueblo, a time I shall never forget. And a time that trina and the earthquake that hit Haiti
a U.S. communications monitoring ship, remains with me in lessons learned. early this year
had been in international waters-legally – • Today the military is a leader in telemedi-
when it was surrounded and fired upon by a As a former naval medical officer, I am cine, sending patient information from
North Korean warship. keenly aware of how much my civilian the battlefield and receiving expert advice
medical practice owes to military medicine. back from around the world to physicians
One crewman was killed and 10 others were Emergency and disaster medicine, in partic- who are on the front lines. This is technol-
wounded before Cmdr. Lloyd “Pete” Bucher ular, are the offspring of battlefield medical ogy that ultimately may be as important
surrendered the ship. Had he not surren- experience. So is public health. to a physician and patient in remote rural
dered, the superior firepower of the North areas as it is to those on the battlefield.
Korean ships would have prevailed and many Here are a few examples: • All of this is a reminder of the impor-
more of his men would have been killed. • During the Seminole Wars in the early tance of learning from one another, of
1800s, Army physicians discovered that being united, of facing obstacles together.
Bucher and his crew – 82 in all – were held quinine was effective in treating people That is my message for physicians today.
in captivity in North Korea for 11 long with malaria
months, during which time they were beat- • Following the Spanish-American War Cecil B. Wilson, MD, President,
en, tortured, starved and humiliated on a in 1898, military physician, Walter Reed, American Medical Association
8
wmj 1 2011 5CS.indd 8 21.02.2011 16:27:59SOUTH AFRICA Healthcare insurance industry
schemes, which are primary to paying for
The Regulatory Framework in the Healthcare private health care, to be regulated [16]. The
Medical Schemes Act 131 of 1998 gives
Insurance Industry: the Council for Medical Schemes (CMS)
power over medical schemes; the CMS
In the Interest of Beneficiaries and Public regulates not only medical schemes, but also
health insurance brokers, medical scheme
administrators and managed care organi-
sations [12]. It also imposes much stricter
controls upon medical schemes themselves
in terms of corporate governance, financial
and membership requirements, and provi-
sion of benefits. The Act states the functions
of the Council in a far more purposeful and
consumer-oriented terms, with a defined
focus on the protection of the interests of
medical scheme members.
To achieve its regulatory goals, the office
of the Registrar participates in the con-
sultative process which aims to demarcate
medical schemes from health insurance be-
Monwabisi Gantsho Michael Mncedisi Willie cause it is the case that the encroachment
of risk-rated health insurance products into
Effective regulatory framework is the key Introduction the business of medical schemes results in
to delivery systems that create a well func- cream-skimming the young and healthy,
tioning healthcare environment, this arti- An effective regulatory framework is critical unfair discrimination against the old and
cle provides an analysis of the regulatory to delivering system reform and to creating sickly, and a risk to the sustainability of
framework of private health insurance as it a well-functioning healthcare market [13]. the medical schemes industry [7]. Another
relates to the protection of benef iciaries and This paper presents such a framework with- critical element of regulating the private
the public within South Africa context. The in the South African context; we give an health care sector is to, on an ongoing basis,
Council for Medical schemes (CMS) which outline of goals that a regulation should ad- revise benefit and contribution structures
is the statutory body established in terms dress. It is important to note that the South to protect community rating, which is the
of the Medical Schemes Act 131 of 1998 to Africa’s health system consists of a large principle that all beneficiaries on the same
provide regulatory oversight to the medi- public sector and a smaller private sector. benefit option pay the same contribution,
cal schemes industry in a manner that is The public sector is under-resourced and and that contributions may vary based only
complementary with national health policy. over-used, while the private sector caters to on an individual’s income, number of de-
Medical schemes that are regulated by the middle- and high-income earners who tend pendants, or both [12]. The regulator of
CMS are insurance institutions that cover to be members of medical schemes (16% of medical schemes is in support of the initia-
medical expenses and provide health care the population in 2009, not significantly dif- tion of a proper consultative and research
insurance in the private sector in South Af- ferent to the 15% cover by medical schemes process towards the development of a regu-
rica. Medical schemes reimburse their mem- in 2000). The demographic structure of latory framework for collective bargaining
bers for actual expenditure on health. A medical schemes implies a differently struc- between healthcare providers and funders
regulatory framework must protect the in- tured health system to that of the general (including the review of the National
terests of Benef iciaries, thus CMS contin- population. This is a worrying factor on the Health Amendment Bill).
ues to effectively engage on regulatory and resulting efficiency of the health system as a
policy developments in the health and in- whole, given the substantial resource alloca- The Bill was published for comments in
surance industries to ensure that the rights tion bias in favour of the medical scheme 2006 with the final comments at the end of
of South African Benef iciaries are protected market. In 1994, the National Depart- February in 2007. The new draft of the Bill
at all times. ment of Health (DoH) allowed medical was submitted to the Minister of Health in
9
wmj 1 2011 5CS.indd 9 21.02.2011 16:28:00Healthcare insurance industry SOUTH AFRICA
July 2007, and is awaiting discussion and Licensing of medical schemes, (market stability and institutional
signature of the State President in Parlia- administrators, managed sustainability);
ment. The Bill seeks to address among other care entities and brokers - Increasing the scope of regulatory
key topics the governance issues for medical transparency and democratizing
schemes, including the fit and proper status A major reason for having regulation is to administrative justice processes by
of trustees. The Bill also seeks to change the protect regulated industries from instability making the Registrar’s Office and
manner in which benefits are designed, so as and lack of consumer confidence caused by market information more accessible
to improve transparency and further reduce poor administration and trading systems. to medical scheme members
incentives for unfair discrimination. Setting up minimum registration and ac-
creditation rules and regulations ensures the Policing registered institutions in terms
efficient functioning of market mechanisms. of their observance of rules for minimum
Goals of regulation Establishing minimum standards and ac- compliance and mandatory standards inter-
creditation rules reduces additional costs of mediaries, such as the observance of:
The role of market regulation is to facilitate overhead spreads created by artificial mar- • Rules of minimum compliance and ap-
the delivery of overarching policy objectives ket signals that are driven by health insur- proval requirements for the registration
through economic regulation and consumer ance administration functions. The Medi- of medical schemes and other institutions
protection [13]. The objective of this arti- cal Scheme Act gives the CMS regulatory within the regulator’s jurisdictional regu-
cle is to assess the regulatory framework as powers over medical schemes, managed care latory environment.
it relates to the protection of beneficiaries, entities, brokers, and administrators. The • Mandatory compliance standards.
thus we focus on the following goals of reg- functions of the CMS are included in Sec- • The regulatory function of: Legal en-
ulations, the regulatory framework [3]. tion 7 of the Act. For the purpose of this re- forcement of provisions emanating from
• Ensuring services (and goods) are safe port, the regulatory functions are expanded the Act and other forms of precedence,
and of high quality. using literature on regulatory theory [7]; such as behavioural incentives legitimat-
• Ensuring fair access to services and they are listed are as follows: ed by enabling rules and guidance notices.
(where relevant) also ensure choice of • The regulatory function of: Adjudicat-
provision. Supervising the conduct of registered in- ing over grievance applications made by
• Ensuring financial solvency of medical termediaries by the Council’s line and staff medical scheme enrolees.
schemes. functions, through the implementation of • The regulatory function of: Educating
• Ensuring transparency and fairness in rules-based bureaucratic style of carrying & Communication of the regulator’s fi-
the contractual relationship between the out Council’s governance function: duciary duty to medical scheme enrolees
medical scheme and beneficiary. • A managerial approach to the regulator’s and, the strengthening of the governance
• Ensuring that health insurance packages function of stewardship, controlling con- function’s role of demonstrating account-
provide adequate financial protection. duct by means of quantitative benchmarks ability over regulated stakeholder and
• Managing key externalities and by-prod- and/or qualitative scorecards, monitoring medical scheme members.
ucts of service provision. observance to preset specification and • The regulatory function of: Sanctioning
• Governance of medical schemes. performance standards by registered in- the business of medical schemes and the
termediaries administration of health insurance busi-
• A collaborative governance approach ness functions.
Regulation in advanced which allows for a joint learning process • The regulatory function of: Observing
market economies in developing health insurance regulatory Fiduciary Obligations arising from Prin-
policy by: cipal-Agent market relationships by, gov-
The regulatory framework of private health - configuring formal cooperative erned schemes and other registered inter-
care insurance industries is administered interfaces between the regulator’s mediaries and, the Regulatory Body itself.
by a government agency or agencies that internal operational line functions
implement statutory requirements, usually and staff function (specialist ad-
with the authority to establish administra- visors) channels, for the benefit Solvency Regulation
tive rules and procedures [9]. This section of strengthening the responsive-
discuses the some of the regulated activities ness of benchmark or peer review Solvency regulation includes solvency mon-
within the health sector and core functions policy tools, economic incentives itoring, capital requirements, other controls
of such regulating entities. and reducing market uncertainties on medical scheme behavior (for example,
10
wmj 1 2011 5CS.indd 10 21.02.2011 16:28:02SOUTH AFRICA Healthcare insurance industry
investment regulations) and, in many cas- number of schemes in the ≥25% stratum • Shall be self-supporting in terms of
es, establishment of beneficiary protection is seen until 2004, from 2005 a downward membership and financial performance.
schemes to pay specified claims against in- trend is observed and the number of schemes • Is financially sound.
solvent medical schemes [9]. Beneficiaries in ≥25% stratum declined significantly by • Will not jeopardize the financial sound-
pay contributions towards medical schemes 21% from 111 to 88 medical schemes. The ness of any existing benefit option within
for future health care spending and the fi- declining trend also correlates to the con- the medical scheme.
nancial capacity for the scheme to respond solidation in the medical schemes environ-
to claims/ pay for healthcare spending is de- ment. There were no significant declines in Regulation 4 of the Act states that medi-
pendent on the schemes viability and finan- 25%) components of section 33 of the Act include greater the number of benefit options, the
and (≥25%) stratum. The phasing in of the the following. A medical scheme: greater the costs of providing these benefits.
statutory solvency reserve requirements was • May apply for the registration of more The CMS continues monitor the registra-
from 2000 to 2004, and upward trend in the than one benefit option. tion of benefit options, ensuring that they
11
wmj 1 2011 5CS.indd 11 21.02.2011 16:28:03Healthcare insurance industry SOUTH AFRICA
140 119
112 111 109 111 108
120 102 97
Number of schemes
92 88
100
80
60
30 30 31 26
40 22 21 22 25 22 22
20
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
year
< 25% ≥25%
Figure 1. Industry solvency trends for all schemes (2000–2009) Figure 2. Distribution of benefit options across medical schemes (2009)
Source: [5] Source: [21]
are self sustainable, affordable to enrollees, ficiency in the allocation of private and Market conduct and unfair
and, indeed, do offer value for money. public health care resources. PMBs are not trade practices
only legislated, but they are the envisaged
platform for the national health insurance Insurance regulators often enforce legisla-
Access to minimal level of care package, which defines the entitlement for tion dealing with market conduct and unfair
any person contributing towards such in- trade practices, such as provisions related to
Many governments regulate most language surance. As a consequence, a package of unfair claim settlement practices and po-
by requiring certain contract provisions PMBs with a focus on catastrophic care tentially deceptive sales practices by medi-
and prohibiting others. Some governments was developed as Annexure A in the Regu- cal schemes and administrators [9]. The
mandate minimum coverage provisions [9]. lations to the new Act in 2000. In terms of regulator of the medical schemes in South
The concept of a minimum level of care is the Regulations, the PMB package was to Africa actively participates in the consulta-
central to the facilitation and achievement be reviewed every two years by the DoH. tive process which aims to demarcate medi-
of a more equitable and efficient qual- This review must involve the Council for cal schemes from health insurance. The of-
ity health care system in South Africa. The Medical Schemes (CMS), stakeholders, fice of the Registrar is acutely aware that the
Prescribed Minimum Benefits (PMBs), as provincial departments of health and con- encroachment of risk-rated health insur-
provided for by the Medical Schemes Act, sumer representatives. ance products into the business of medical
have had the greatest importance. PMBs schemes results in cream-skimming, unfair
are minimum benefits which, by law, must A review process of PMBs was begun by discrimination, and a risk to the sustainabil-
be provided to all medical scheme mem- the Council for Medical Schemes in 2008 ity of the medical schemes industry.
bers and include the provision of diagnosis, [4]. Comments from the stakeholders on
treatment and care costs for: the document were taken into account and Effective regulation of medical schemes –
• any emergency medical condition; publication of the third draft of the re- and the protection of beneficiaries – is criti-
• a range of conditions as specified in An- port in that process was published on the cally dependent on all entities and products
nexure A of the Regulations to the Medi- CMS webpage. This process was finalized being subjected to the rigorous oversight
cal Schemes Act [12], subject to limita- in 2009/10 and the final draft regulation and strict protections are contained in the
tions specified in Annexure A; included was submitted to the Minister of Health for Medical Schemes Act. A serious threat
in this list of conditions are chronic con- consideration for possible publication in the is posed to the sustainability of medical
ditions. government gazette for public comments. scheme risk pools by the recent prolifera-
There are, however, challenges with the im- tion of insurance products which seek to en-
PMBs were introduced to avoid inci- plementation of the Act and Regulations croach on the preserve of medical schemes.
dents where individuals lose their medical relating to PMBs. In this regard the CMS Thus, the CMS continues to participate in
scheme cover in the event of serious illness continues to engage with the provisions of the demarcation work group established by
and are put at serious financial risk due to PMB regulations, including the “payment National Treasury to draft regulations in
unfunded utilization of medical services. in full” provisions contained in regulation 8 support of certain amendments effected to
They also aim to encourage improved ef- of the Medical Schemes Act. the Long- and Short-Term Insurance Acts
12
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