I don’t buy FDI’s arguments.

Doctors take the Hippocratic oath and abide by its ethic “Primum non nocere” (Do no harm) – businessmen’s main ethic is to make money!

To partner a doctor and A businessman and say one complements the other (“a doctor can do what he knows best – doctoring whilst business partner takes care of “marketing, accounts, IT, billing, credit control and banking”) ignores the difficulty of drawing a line between medical ethics and business profit, and assumes that the doctor will not in his practice be influenced by his partner and his business considerations. It ignores the fact that the doctor may be beholden to defer to the business imperatives of his business partner who finances the whole set up and infrastructure of the clinic. It ignores the fact that the business partner may have more say, leverage and power in that partnership. It mentions complementarity without factoring the inherent conflict of interest. It ignores that billing, collection and credit control can be outsourced by physicians to outside accountants and other consultants. To me, (I must confess a layman and non doctor), there’s certainly all the appearances as well as potential reality of conflict of interest. For examples :-

(a) Patients may be persuaded to undergo more expensive technical procedures that rake in the profits in borderline situations in which more conservative, less expensive options might be just as acceptable;

(b) Worse still, take the case of (say) an “eye doctor” (opthalomogist) who knows there are certain risks in refractive surgery/laser as a remedy to cataracts and who feel that the risks of the procedure did not justify the benefits and would normally not recommend it unless with the risks and pros and cons fully explained but his business partner now tells him, “don’t tell the patients too many things, they can’t weigh the options rationally, do your best, it is a recognized procedure that you can’t be faulted, do it, it pays well RM4,000 per surgery that takes only an hour (see how many you do a day?), don’t forget I and we have obligations to service interest to banks for their loans, pay premiums to cover our liability, and most important our money – profit sharing – don’t you want more? Isn’t that the reason we partnered in the first instance?”

(c) Many tests, procedures, and operations, which may have not yet been fully evaluated or scientifically compared with other available measures for cost effectiveness may be recommended by a physician influenced by his business partner if these are well paying!

(d) Also pharmaceutical prescriptions marginally useful if at all may be recommended because there is a profit margin in sale. It is so much easier to prescribe antibiotics (to which bacteria rather than virus responds to treatment) for a common flu from virus if the ancillary profit motive is existing, the Hippocratic ethical reservation being assuaged by the rationalization that whilst antibiotics does not good, it does not, at the same time, inflict harm on a patient with no known allergies!

In comparing “other industries” and arguing whether “buses must be owned by bus drivers or conductors, engineering companies be owned only by engineers or Genting should not own a power plant as they are only experts in gambling”, FDI neglects to differentiate that doctors like lawyers, engineers and accountants etc are professions that have their respective traditions, ethics and objectives – which, I must add, are very distant from the commercial objectives of profit!

Then FDI refers to “large private hospitals in this country with all their various specialist clinics are owned by such corporations as KPJ which are public-listed, Sime Darby, Tabung Haji, Pantai Hospitals, Sunway, Gleneagles, are all owned by businessmen”.

Here, he entirely ignores the scale of operations involved and their different roles in holistic scheme of healthcare; he ignores that physicians run their own clinics within the hospitals; obviously the costs of equipment in a hospital and costs of running it are of different scale that require participation of investors and businessmen but that does not necessarily mean that the doctors having their clinics within such a set up cannot negotiate more independence at least in whatever that happens inside the clinic.

Even then commercial considerations would admittedly intrude – the hospital’s board of directors and shareholders – will expect the medical practitioner to make enough to pay for contributions to leasing costs of expensive equipment of the hospital and pay rental for his clinic but still the situation is not on all fours with a clinic as distinct from a hospital. Being smaller, both medical and non medical partners, run the clinic in an inextricably interdependent and indivisible manner with stark blurring of lines when it comes to medical decision of a physician being influenced by business decision.

I won’t argue with the fact that ultimately it depends on the character and ethics of a doctor as a person. But who are we to know which doctor is good and which is not so and who will when tempted by money turn from good to bad? It is the frailty of human nature that one cannot depend on it alone to ensure that all good results will happen. Human nature needs to be buttressed by institutional checks and balance – not just in medical practice but as we all know here the practice of politics as well! Why subject a doctor to temptation or pressure from a business partner of a clinic?

What I am saying is that conflict of interest – conflict between Hippocratic Ethics and Money – is softened and better guarded against (as distinct from entirely eliminated) by not subjecting private practitioners in clinics to additional pressures of business partners and their commercial objectives.

It is agreed that the winds of change blow over the past few decades affecting the economic dimensions of medicine as technology and organization of medical practice have become increasingly specialized, complex, and expensive, with diagnostic and therapeutic technology now expanded at great costs, which is why hospitals require business men to invest and medical insurance becomes necessary.

But MOH and the Private Healthcare Facilities and Services Act 1998 (PHFSA) address the private clinics (smaller than hospitals) that are supposed to play a role to help patients not requiring hospitalization and to play the complementary role of referring them to hospitals if the patient’s condition requires so. The clinics are not supposed to be hospitals so that what is applicable for hospitals (investment by businessmen) is automatically applicable for clinics, as what FDI appears to argue! I believe private clinics have separate role to complement hospitals rather than compete with them in health care and making money!

That is why the PHFSA clearly states that “person in charge of a registered private medical clinic” shall be a registered medical practitioner as spelt out clearly in Third Schedule of the PHFSA.

It is already law. I am sure FDI would be aware of this. If he wants public opinion to side him to amend this to include non medical businessman to co-operate a private clinic, he must come out with more persuasive arguments than that which he has, so far.