ORIGINAL ARTICLE

Ethical basis for charging medical fees

Lopa Mehta

T his essay will discuss the ethics of

medical fees charged by doctors in
their individual capacities, for services
is ultimately recovered from the
patient and hence forms a component
of the medical fee. The kickback givers
money to speculate in real estate.

Unethical justification for

rendered to patients. There is no are consultants, pathologists, fees
rational basis for current practices in radiologists and those who run Now let us go over some unethical
fee charging. There are no laws or laboratories and small nursing homes. means for justifying the charging of the
norms in this regard. Also, what is and General practitioners top the list of fees.
is not ethical varies with recipients. Others both give and
circumstances, from person to person receive. A cardiologist pays to a n A general practitioner buys pills
and place to place. Still, we will general physician for referring a patient at the wholesale rate, but dispenses
attempt to identify and elaborate the for a ‘plasty’ and the cardiologist takes them at much higher prices, in addition
areas which can be definitely called from the cardiac surgeon, the last in to his consultation fees.
unethical – the avoidance of which is the chain. No wonder the surgeon’s n A family physician accompanying
the first step towards ethicality – and charges tend to be exorbitant. a patient to a consultant charges for
evolve basic principles to guide fee This brings us to the next unethical the visit – and also anticipates a
structuring. part of charging fees: under-the-table, kickback from the consultant.
In our society, professionals are more unaccounted for money, beyond the n General practitioners running nursing
respected than are manual labourers. hospital’s official tarriff. This can never homes can be tempted to advise
This is partly because of the rewards be justified. Instances are even unnecessary admissions, and prescribe
professionals are paid for their work, reported of families being held to unnecessary treatments.
which in turn produces a gap in the ransom half-way through an operation. n Surgeons perform sham operations
income between the two groups. Both the cut practice and under-the- - this is more common when patients’
Both the physician and society as a table charges represent avarice and paying capacity is very high.
whole are responsible for this scenario. extortion. The recipient of a cut wants n Unnecessary investigations only
Society believes that the more a doctor to earn without labouring. Charging help to swell the doctor’s coffers.
charges, the more competent s/he must under the table is also misuse of one’s Physicians prescribe ECGs, stress tests,
be, and the better the associated technical and knowledge know-how to ‘plasties’, ‘scopies’ or laboratory or
services. Society is also result- earn by exploitation. radiological investigations, depending
oriented: health is seen as a commodity on the speciality involved. The doctors
that a doctor can easily provide. Other frauds benefit directly or indirectly through
Spending money for relatives is There are doctors who charge fees kickbacks.
equivalent to caring for one’s near and without issuing receipts. This form of n Unnecessary follow-ups also
dear and fulfilling one’s obligations to cheating generates unaccounted-for or represent misconduct. Charges are
them. black money. However, doctors alone heavy for a “Ct all” follow-up. Calling
The doctor also sends the message are not to be blamed here. Patients a patient for a check-up when it is not
that s/he alone can provide good often force doctors to take cash without required, is unjustifiable, and
health. This is not a recent a receipt if they want to pay with exploiting the patient. Only those
phenomenon. Centuries ago, unaccounted-for cash. situations in which active evaluation
Archimatheus spelled out the The availability of insurance has and management decisions are to be
physician’s code of conduct: “Even if given rise to other unethical practices. taken call for follow-up charges.
no medicine is necessary he should When an insurance company or an n Owners of small nursing homes
prescribe some harmless concoction, employer will reimburse expenses, exploit with the Intensive Care Unit.
lest the patient think the treatment not patients and doctors sometimes The essence of an intensive care unit
worth the fee, and lest nature should conspire to inflate receipts, and share is skilled manpower. Private ‘ICUs’
seem to have healed the patient without the excess amount If there is a ceiling charge high rates for their services,
the physician’s aid.” on reimbursement, a request is made though they often have only a junior
for the bill to be split, and made for doctor on call.
The kickback and under- two different dates. Sometimes the
the-table fees n We are not entering the arena of
doctor is even asked to replace the
corruption in medical practice
A pervasive unethical practice is the patient’s name with that of the working
introduced by pharmaceutical
kickback or cut practice. The kickback next of kin who is entitled to get the
companies. Their free holidays with
amount reimbursed.
airfare, cocktail dinners and other
Dr Lopa Mehta, department of Such practices naturally have hospitality are an insidious way of
anatomy, Seth G.S. Medical College, contributed to many unhealthy trends charging patients by doctors through
Parel, Mumbai 400012. in society. Some doctors use their black pharmaceutical companies. All the

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ORIGINAL ARTICLE

expenses incurred by pharmaceutical prosperous career, but as a vocation for In today’s times, the following factors
companies are finally borne by those who have an inner urge to serve could be considered towards
patients. mankind. Doctors would be sanyasis, computing charges:
Another area of malpractice is not competitors in society. n Seniority, competence,
advertising by doctors — whether Till this dream comes true, the State experience, qualifications and the
soliciting work or taking advantage of cannot take full responsibility for difficulty involved in the service
public and private hospital medical care. It should continue to n Equipment and establishment
attachments. These too are unethical provide for the poor and for emergency running cost
means of charging patients. Of course, care. The private practitioner should
n Time involved
controlling bodies have neither the remember that the doctor’s role
power nor the inclination to regulate surpasses even that of a priest. Doctors n Locality where the practice is
such practices. Practitioners of are not purveyors of health but carried out
alternative systems of medicine openly caretakers of sick bodies, and therefore n Cost of living.
advertise tall claims of cures for every of sick souls as well. In other words doctors’ fees should
illness, but no governing body seems If a code for charging fees could be allow a doctor to live decently
to be bothered about this. established 4,000 years ago, we could (fulfilling needs, not ‘wants’) and
evolve one for our time, striking a enjoy a certain social standing; to
Basis of material returns balance between “swartha” and recover the cost of running the
What is the doctor’s financial and “parmartha”. establishment, and to keep up-to-date
intellectual in-put, on which basis s/ The code of Hammurabi prescribed so as not to depend on the
he expects material returns? We live in 4,000 years ago was as follows: pharmaceutical industry for
a materialistic world. This culture of continuing education.
If a doctor has treated a gentleman
consumption breeds avarice and At the individual level, doctors must
for a severe wound with a bronze
corruption. As our population goes up, balance their personal requirements
lancet and has cured the man, or has
so does the number of takers for the with their patients’ needs. A
opened an abscess of the eye for a
same small pie. “subhashita” in Sanskrit advises a
gentleman with a bronze lancet and
Medical practitioners go through has cured the eye of the gentleman, he sanyasi against eating at a doctor’s
many difficulties before establishing shall take ten shekels of silver. house because he has earned from
their practices. Private medical another’s suffering. Let us pray that if
If the patient be the son of a poor
colleges, capitation fees, bank the doctor charges fairly, he will not
man, he shall take five shekels of silver
guarantees and increased tuition fees be considered a physician who has
to the doctor.
have sent other costs spiralling. Time unfairly exploited his skill and
and money is invested amidst stiff If he be a gentleman’s servant, the knowledge to earn money.
competition. Once a doctor qualifies, master of the servant shall give two
Law is not a solution to this problem.
s/he must bear the high costs of setting shekels of silver to the doctor.
Only self-imposed discipline can
up a practice, space, equipment and If a doctor has cured the shattered ensure a healthy service to the sick
running an establishment. This means limb of a gentleman or has cured the patient, without kickbacks or other
borrowing, which in turn means diseased bowel, the patient shall give unlawful charges.
repayment with interest – a vicious five shekels of silver to the doctor.
cycle. If he be the son of a poor man he shall
Besides, people’s expectations have give three shekels of silver.
Capital punishment: the
gone up. The executive culture has big question
If a gentleman’s servant, the master
arrived. Credit cards have become of the slave shall give two shekels of Can a doctor be ethically involved in
status symbols. Simple meals at home silver to the doctor. capital punishment? In response to
are not enough. Fancy restaurants and this frequently-asked question,
extravagant entertainment are seen as Some principles emerge from this
perhaps what is needed is not so much
code:
not just desirable but necessary. At the a discussion on medical ethics as one
same time, old-fashioned ideals of n The fee will vary with the type of on capital punishment itself.
integrity have been abandoned for the illness. For curable and accidental
It doesn’t take much to realise that
easy way to wealth without considering illnesses, the charges are high. They
capital punishment does not serve any
the means. are less for life threatening conditions.
of its avowed purposes. All it does is
If these pressures were not enough, n The fee depends on the patient’s spend a lot of money to kill a few
the doctor must also worry about the paying capacity. people arbitrarily and satisfy some
fact that medical services are now n For an employee dependent on perceived need for blood revenge--
covered by the Consumer Protection the employer, the treatment’s cost is while people with the money and the
Act. borne by the employer. connections get away free. Maybe we
We should look for the day when n Charges cannot vary grossly from should be more worried about whether
medical practice will not be seen as a doctor to doctor for the same service, the medical profession is doing its job
way for the brilliant to make a in the same area. providing health care.

• Issues in Medical Ethics, VIII (2), April-June 2000 •

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