On November 13, 2024, M. Vignesh was caught on camera attempting to flee the Kalaignar Centenary Super Specialty Hospital (KCSSH) in Guindy after stabbing oncologist Dr Balaji.
The incident has sparked widespread protests and led to boycotts across the medical community, including demands to have tag systems for patient attendants to enhance security. Dr Ezhilan, a physician and MLA, urged the public not to sensationalise such incidents, stressing the importance of measured discourse.
Chief Minister MK Stalin has ordered a detailed inquiry into the attack and pledged to implement stronger safeguards to prevent similar occurrences in the future.
Around the same time, doctors across the country have been protesting in the wake of the brutal sexual assault and murder of a postgraduate trainee doctor on August 9, 2024, in Kolkata. Their demands include justice for the victim, the resignation of senior health and police officials, enhanced security for healthcare workers, and an end to the prevalent ‘threat culture’ in government healthcare facilities. They also demanded a state grievance redressal cell.
Junior doctors have also called for specific measures to improve their working conditions, including the installation of CCTV cameras, the presence of female security personnel, 24-hour access to doctors' canteens and drinking water, as well as separate restrooms and bathrooms for on-duty doctors. Similar arrangements have been requested for nurses. Additionally, the establishment of a state-level grievance redressal cell has been highlighted as a priority.
On August 18, the Supreme Court of India suo motu took cognizance of the case and expressed concern over the virtual absence of safe working conditions for doctors in public hospitals. A national task force was set up to formulate a protocol for the safety of doctors.
After the assault on Dr Balaji, the Indian Medical Association (IMA) was quick to respond. They said no amount of superficial damage control exercises by governments would make doctors work without fear in this country. IMA demanded proactive security measures in hospitals to ensure the safety of doctors, strong deterrent legislation and exemplary punishment, stating “the medical profession of the country is deeply disturbed and is sceptical of the remedial measures for this ever-recurring violence. Only a comprehensive overhaul of the security atmosphere in the hospitals could restore the confidence of doctors. The nation owes this to its doctors”.
A lot of the frustrations and anger expressed by doctors and their families are legitimate and need to be addressed on an urgent basis. For doctors, who are exhausted after hours of hard work, to have to additionally be worried about rape or violence even within the workspace, can take a terrible toll on their mental health and sense of well-being. For parents and family of those who work in these conditions, it can be a fearful wait till such time the doctor comes home. Several structural issues related to human resource development, appointments, infrastructure etc. are non-negotiable for an effective and functional healthcare system. A tired and over-worked health worker is unlikely to be able to provide the quality of care required by the system.
While it is true that the nation owes its doctors safety among many other things, the discourse cannot end at that. It would be a terrible lapse not to simultaneously address several other structural and systemic issues that the health system in India is embedded in. The questions that must necessarily also be asked are what do doctors owe the nation?
Dr Kiran Kumbhar says that the framing of the Kolkata rape and murder leaves a lot to be desired and that the IMA demonstrates ‘doctor exceptionalism’ by focusing on ‘doctors’ safety’ rather than that of all women healthcare workers. The female human resources in the healthcare system are not entirely doctors. Nurses, pharmacists, lab technicians, X-ray technicians, cleaners, hospital aides etc. could be women who are fewer in number than doctors and therefore likely to have more frequent night shifts. ASHA workers function in difficult and disagreeable circumstances, accompanying women in labour to a health facility at any time of the day or night.
Do all these women healthcare workers not deserve a workplace that is safe and free of sexual harassment and violence? Would there be protests if there are incidents of sexual assaults, harassment, inappropriate touching, examination without consent by healthcare personnel of women patients? What if male healthcare workers, including doctors, sexually assault other doctors, nurses, other staff or patients? Would the Supreme court take suo moto cognizance even then? What about the State and Union government? Would they put systems in place against abuse, violence, assault, humiliation by healthcare staff towards patients and others?
For many Indian doctors, there seems to be an ingrained belief that they are beyond the reach of regulatory mechanisms and that patients should not question or challenge them. This may explain why many in the medical community have opposed regulations aimed at ensuring ethical, standardised and evidence based healthcare.
Kumbhar explains how doctors have ‘hardly taken any steps to curb the pervasive violence, verbal and physical, that underprivileged patients experience every day in medical settings’ and that a ‘potent combination of entitlement and victim mentality’ of the doctors has led to many unfortunate consequences.
Doctors have a responsibility not to subject patients to cruel, inhuman or degrading punishment. How often do doctors call out their colleagues or stand witness against bad behaviour towards patients or other healthcare staff? Do doctors come out in large numbers to undergo ‘fast unto death’ when patients are forced to undergo unnecessary procedures or lose limbs or lives due to negligence?
Senior doctors can be visiting consultants at several different hospitals and government doctors may have private practice which gives them less time with individual patients. Even if they are just a phone call away, they hold vicarious responsibility and liability for lapses in patient care.
Do doctors ask each other ‘Why do you prescribe expensive and unnecessary tests without even examining the patient?’ Do female doctors pull up their male colleagues for not having a female attender when female patients are examined?
Doctors in India are quite vocal about their own rights but resistant to acknowledging responsibilities, leave alone patient rights. When patients demand rights such as accountability and grievance redressal, doctors are outraged. As Dr. Devi Shetty famously asked ‘Are we terrorists that we should be regulated?’
Doctors have a duty to explain to patients about risks, complications and potential side effects. If attenders are forced into catastrophic health expenditure, In spite of zero chance of patient survival, will doctors and the system be penalised?
Doctors have the duty to ensure that patients have the best level of care. They need to explain to patients in a language that they understand about available treatment options and the pros and cons of each. This includes getting a second opinion, referrals, expert consultations etc.
It is not the patient’s duty to accept all actions by doctors unquestioningly. When the IMA threatens that doctors under threat of violence may end up practising ‘defensive medicine’, it seems to imply that ‘If you don’t protect our doctors, then they are not responsible for unethical practice’. However, as per the basic ethics of medical practice, a doctor is expected to be skilled at clinical examination and diagnosis, taking recourse to laboratory and other diagnostics only if needed.
A doctor also needs to situate their care on evidence-based medicine rather than caste, class, gender, communal and other prejudices. The havoc and disruption they cause to patient care because of these prejudices are not particularly challenged by their colleagues but rather reinforced and enabled. Just as doctors have freedom of religion, belief and opinion, patients also have these same rights even if it differs from that of the doctors. Doctors have a duty not to harass patients, colleagues or others on the basis of sex, gender, caste, sexual orientation, race or any (presumed) group characteristic.
A doctor has a right to choose his or her patient(s), but this cannot come from a premise of unfair discrimination and neither should emergency care be denied. Are doctors employed in government hospitals called out by their professional colleagues for having private practice which takes away from quality care to patients in government hospitals?
It is no secret that doctors who have gained admission through reservation or affirmative action face harassment, discrimination and abuse. So, not only do doctors believe they as a group are superior, there are also deeply held prejudices that only certain caste groups are ‘fit’ to do medicine. Doctors from oppressor caste groups publicly display ‘general merit’ and ‘unreserved’ on their profiles and advise people not to go to ‘reserved category doctors’ as there is no ‘guarantee’ that they will be treated well. Where is the inter-doctor solidarity here? Why are doctors not protesting the horrific casteism being practised within and by the healthcare system? When Muslim patients were targeted by the health system during the Covid pandemic and otherwise, have doctors protested that this goes against their medical ethics?
According to Human Rights Watch, ‘one challenge for accountability in custodial deaths is the propensity of government doctors to back police claims. Autopsy and forensic reports frequently support the police version of events even where there is no apparent basis’. Do doctors reject colluding with police and prison authorities in cases of custodial torture?
The sad reality is that a majority of patients in India are tragically adjusting to even the worst behaviours by doctors. Doctors throwing files, abusing patients, refusing to see them for some perceived violation, negligence, unnecessary tests and procedures is not at all rare. In many instances, patients respond with exaggerated gratitude to even the smallest demonstration of care or compassion by a doctor. That a doctor ‘tried’ is often enough for attenders to accept adverse outcomes.
So, the real question before doctors and their loved ones who are protesting for safe environments, is not whether your demands are legitimate or not, because most often they are.
Can you also include in your demands and protests against sexual assault, all women within the healthcare system, including patients? The real question then is not whether it is ‘all men or not’, but crucially whether it is ‘all women or not’
The demand for a safe workplace has to delve deeper into whether patients also feel safe within the healthcare system. Can patients become stakeholders to create health facilities and systems that are evidence based, ethical, compassionate, affordable and universal?
The doctors own rights are inextricably linked with the rights of other healthcare personnel and patient rights. - we cannot demand one while denying the other.
Dr Sylvia Karpagam is a public health doctor and researcher. Views expressed are the author’s own