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Well, like any normal slightly paranoid patient, my mind wandered to all the horrible things that could go wrong. What if this or that happened? Being a doctor, one sometimes suffers from knowing too much. Perhaps a layman would be blissfully ignorant. But is ignorance bliss? Or a good reason to sue the doctor should something go wrong? How aware is the average person of the myriad complications that can arise from any medical treatment or procedure? And how much does the average person really need to know. Or even wants to know? Medical consent in this country is now held up to the standards of the (in)famous "Whitaker principle". Rogers v Whitaker was a case brought before the High Court of Australia in 1992. The plaintiff was Maree Whitaker, who was blind in her right eye as a result of an injury at the age of 9 years old. However, for 40 years subsequently she had lived a very normal life despite her one sided blindness. She was then advised by her ophthalmologist, Dr. Christopher Rogers, to undergo elective surgery in an attempt to improve the appearance in that eye and possibly to restore the vision. The operation was conducted with due care and skill, but unfortunately not only was the operation not successful, but the good eye was involved in a rare complication called sympathetic ophthalmia and became blind. Thus the outcome was that she lost the sight in her remaining good eye. The patient sued the doctor, and won. The judge’s decision was based primarily on the fact that the plaintiff was not informed of the possibility of the good eye going blind, and that she would not have consented for the operation if she had known. Here it is worth noting that sympathetic ophthalmia is extremely rare, occurring at an incidence of 1 in 14,000. And not all cases result in the eye going blind. The Rogers v Whitaker judgment stated that a health professional has a duty to warn a patient of a material risk inherent in proposed treatment. A risk is considered to be material if :
How do we decide which of the complications should be specifically informed to the patient. It’s easy to say ‘all material risks" as defined above; but the risks that accompany any procedure are innumerable if one includes all the very rare possibilities. Does a 1 in 14,000 risk seem reasonable to be included? Is the average person able to ‘weigh’ and appreciate the dimensions/ implications of such a rare risk? Therein lies the dilemma. Do we inform the patient of everything conceivable that can go wrong, or only of risks that are above a certain probability? For an appreciation of the relative risk of 1 in 14,000, the following are useful comparisons; the risk of any presently healthy individual dying within the following year of the following conditions are:
Would we be doing the patient a favour by enumerating every rare complication if we recognise that the patient may be unable to weigh and discern the relative risks, and as a result of an exhaustive (and frightening) listing of the complications, will more than likely refuse an operation or procedure that will save his/her life or at least give major alleviation of his/her condition. In an increasingly litigious climate, doctors may choose the easier path of ‘playing by the book’ and letting the patient take responsibility for his/her choices, however misguided we may think they are. However is such a ‘defensive’ practice an abdication of our moral duty to do the best for our patients? Down this slippery slope is the future scenario where Malaysian doctors will walk away from an accident instead of rendering help for fear of being sued subsequently. Therefore it may not be wise to apply the Whitaker principle blindly in our local context. I am not being condescending when I say that I work with many patients/parents who are unable to make the same level of informed choices as their more educated/prosperous urban cousins, and certainly not as the more educated community from which the Whitaker case comes. I am not being paternalistic when I say that a certain segment of our population would still like to have the doctor make some decisions, provided that they are done in their best interest. I think the challenge for us is how to find a balance between the two - being able to respect the patient’s right to information and autonomy of choice, versus the need to sometimes bear some responsibility to make decisions that are for the best of the patient though they may subject us to some medico legal risks. So while a literal reading of the Whitaker case means that one would have to defensively inform the patient of every ‘material’ risk so that the patient cannot turn around and sue us later, a more responsible approach is still for us to assess the individual and sometimes bear some risks for the sake of the patient. And ultimately the response of the patient to an adverse outcome or complication of a treatment/ procedure will depend on the rapport we have built with them. And the trust that our patients have in us is the fundament of our profession. This cannot be replaced by any amount of sophisticated equipment or the latest fantastic modalities of treatment. Nor should its absence be accepted as an inevitable state, and legally covered by defensive medical practice. That need for trust is both the bane and boon of our profession. Instead of conveniently running away from that responsibility, we should embrace and celebrate that uniqueness of our noble profession. Soo Thian Lian President 2007 - 2009 And dare we ask, what is the relevance of MPA? In an attempt to answer these questions, the Executive Committee locked itself up in the Cameron Highlands on 9th September 2007, together with many of the State MPA and subcommittee chairpersons. Well, perhaps locked up may be too strong a word, but certainly the idyllic location far from the madding crowd, amidst lush green rolling hills dotted by low lying clouds, helped those present to temporarily put aside the pressing matters of day-today life to focus on the matter at hand - to take stock, and plot new directions for the Association. The matters discussed covered the following areas of concern:
Of the many areas covered there is one that I would like to expand further; and that is the role of MPA in advocacy for the health, wellbeing and rights of the child in our country. I hope to see the Association coming of age, and becoming a more confident spokesman for the rights of the child. I have found it rather ironic that children’s rights are not on the fore-front in a country like ours, where the young still form a large proportion of the population. Unlike the developed countries where the demographic distribution is largely a vertical cylinder with the aged increasing in numbers and proportion, our country is still young and the demographic pattern is still that of a broad base with a tapering (although visibly widening) top. Thus one would have thought that children will be given the first consideration in our planning and policies. However we are all too familiar with the scenario where priority is given to the Datuks and YB’s in various situations, including hospital planning and allocation of health resources. I guess that’s not hard to explain when one remembers that the decisions are often made in the light of political expediency, instead of the noble principles of ‘the most to be given to those with the greatest need’, and that of the ‘protection of the disadvantaged and vulnerable’ amongst us. In 1989, the United Nations created the seminal document called the Convention on the Rights of the Child (CRC), a powerful document designed to ensure that children are protected and given the opportunity to reach their full potential. This Convention builds on the previous Declaration on the Rights of the Child, which was itself formulated 30 years before that in 1959. The 4 core principles of the CRC are non-discrimination; devotion to the best interests of the child; the right to life, survival and development; and the respect for the views of the child. Consisting of 54 Articles and two subsequent Optional Protocols, this Convention has been signed by 190 countries, including our own. So how have we performed? Have we provided well enough for the needs of the child, both in the medical field and nonmedical areas? While we are not exactly criminally negligent, there are many areas where there has been governmental and institutional neglect. Article 24 refers to the rights of the child to the best medical and health services. Are we ensuring equity of care across the country, or are we happy just to let the geographically and economically advantaged areas thrive and leave the others to languish? Are we prioritizing the child in our policy and plans? Article 22 refers to the rights of refugee children. While that remains a sticky political issue without easy solutions, are we in the meantime ensuring humane treatment of these stateless children? Or are we conveniently rendering these children invisible, so we do not have to feel the guilt of not addressing the wellbeing of this unspoken-for group of children, some abandoned when their parents are repatriated, to roam the streets and fend for themselves the best way they can? It’s so sad to see such children in Sabah being systematically neglected; I have visited Vietnam and Cambodia, and felt the shame of realizing that there are children in our bountiful country who are in a worse state than the children in our poorer neighbouring countries. Article 23 refers to the rights of disabled children. Are we providing adequately for these special children? Are we allocating enough of our funds and resources for this group of our community, the treatment of whom reflects how civilized and humane we are as a society? The road is long, and there is still a long way for us to go on the journey. And in the words of Chilean Nobel laureate Gabriel Mistral, the time to act is NOW. "We are guilty of many errors and faults, But our worst crime is abandoning the children, Neglecting the foundation of life, Many of the things we need can wait, The child can not, Right now is the time his bones are being formed, His blood is being made, And his senses are being developed, To him we cannot answer "Tomorrow" His name is Today... Dare we answer "Tomorrow"?" --Gabriel Mistral Soo Thian Lian President 2007 - 2009 Firstly, I should thank our outgoing president Dr. Zulkifli Ismail for his impeccable term of service. He has been instrumental in the success of many key programmes of the Association, chief of which are the Positive Parenting and the Make It Safe For Kids programmes. Despite being new in private practice, he has invested a lot of his personal time and attention into the many activities these have involved. He will be a hard act to follow. The recently concluded 29th MPA Congress went on smoothly and successfully in picturesque Kuala Terengganu. In addition to an involving scientific program, we had many broad smiling faces toting shopping bags filled with batik, keropok and lekor. Many thanks to the local organising committee, and of course, the very able secretariat under the leadership of the tireless Datin Saadiah. What directions do I see for MPA in the coming years? I hope to see more active involvement by the various state committees. Each committee is given seed money of RM2,000 to start their activities at the local state level (with option for more funding on a need-to basis), but not every state has taken up this opportunity. Undoubtedly, the various paediatricians have been organising various activities on their own initiative at their local level, often in conjunction with various NGOs and government institutions. I hope that they will choose MPA as their partner in these activities. This will be a win-win situation whereby the administrative support and experience of the central MPA secretariat is made available to the various states, and in return, MPA is strengthened and made relevant to the medical community, and the community at large. That would be a significant step in making MPA the leading platform for paediatricians and those who work towards improving child health care in the country. Another area that we can and should get more active in is the arena of social service. The Association gives 10% of the profit from our annual conferences to the Malaysian Paediatric Foundation. This money has been fruitfully rechanneled into various training and educational activities over the years. As was discussed in the recent AGM in Kuala Terengganu, perhaps it would be good if the Association in conjunction with the Foundation, could increase its activities in the realm of social/welfare projects. In the past, we have given grants to medical volunteers who have participated in various medical relief programmes overseas. I would like to see this dimension of social conscience strengthened and developed. We have been blessed with bountiful finances as a result of successful annual conferences. We should now look more actively into giving to the community through more welfare oriented projects, either through the Foundation or directly through the activities by the various state committees. We have successfully bidded for the 2009 International Association for Adolescent Health (IAAH) World Congress. This will be a major meeting on the world congress calendar addressing the issue of adolescent health. This comes at an appropriate time in the development of our services as we are in the midst of persuading the Ministry to officially extend the paediatric age coverage to 18 years. We will have to work hard over the next two years to make this congress the resounding success that we have come to expect from ourselves. So, let’s all put our shoulders to the wheel and work at the challenging tasks ahead, or perhaps a more appropriate phrase for our present age would be Captain Kirk’s "engage warp engines, full speed ahead". Soo Thian Lian President 2007 - 2009 |
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