A pair of hand-knit woollen socks and the ethical dilemma of a young doctor

16th March 2014

Her face looked familiar.

I slowed my car and took another look — yes, it was she.

It was a Saturday evening and I was on Kamaraj salai in Puducherry, looking for a shop where they repaired kitchen utensils. The blades of one of the bowls of our mixer­-grinder was stuck for more than 6 months ­( or was it an year?)­ and finally my wife was successful in convincing me that we needed to get it repaired. I spotted the shop from a distance and was trying to park my car in front of it, when I noticed the lady at the counter. She was unmistakably a patient with Chronic Kidney Disease (CKD) under regular follow up at our OP clinic, in JIPMER.

It was probably not more than a couple of months back that she last came to the OP Clinic. The OPD was crowded that day and I was upset when a middle aged lady came into the consultation room out of turn and requested to be seen immediately. Apparently she was working in a shop somewhere in town and the shopkeeper was tough on her. He never gave her leave to attend hospital, it seems. She was suffering from CKD and this meant lifelong treatment. She could not afford to buy medicines and to get her monthly supply of medicines from JIPMER pharmacy she had to meet her doctor every month and get a new prescription. This meant a trip to the hospital once a month and reaching the shop late on that day. She claimed that she has to work on Sundays and holidays as well (are there no labor rules in this country?). The employer mercilessly deducts half a day’s salary every month and that day the way the OP was crowded, she was at risk of losing a whole day’s pay. Knowing that trying to argue with her is going to waste time than saving any, I asked her to take the seat. I checked her BP, inquired about her health, handed over the prescription, and forgot about it.

Now I was going to confront her again, as a customer. Given my past experience with my patients when I met them as a customer, I decided it was better that I do not go in person to her. For a minute I considered continuing my search for another shop to get our work done, but the ‘boss’ was in no mood to waste any more time searching for elusive repair shops. I parked my car and told her about the lady being my patient. I decided to stay back in my car and my wife went to the shop. Contrary to my expectations, the lady told my wife that the blade can be repaired only by Monday and asked us to collect the same by that day evening. Now, this was unexpected and foiled my plans to keep away from my patient, because my wife was supposed to return to Chennai the very next day and was not expected to return to Pondy for a good 3­ or 4 weeks.

She recognized me the instant I entered the shop on Monday and in pleasant surprise asked what I wanted. I handed over the receipt I had with me and requested delivery of the repaired bowl. She found it in a minute and handed it over, commenting “Ithu ungaludayuthu endru enakku puriyave illai, sir” (“I didn’t know that this was yours’, Sir”), and I smiled to myself, at the reason. Then came the difficult part. I asked her how much it cost me and took out my purse, but she politely said “there is no charge”.

This was what I expected and wanted to avoid. I remembered the picture she painted about her employer and I was afraid that the guy will deduct the repair charges from her salary. I told her that I do not want the repair to be made with her salary. “Athu naan pathikerey, Sir” (let me deal with it, sir) was her prompt reply. I insisted, protested and requested, but she stood her ground. Other customers had come to the shop and she had to attend to them and the conversation with me risked her condition being revealed to strangers. I made to her one last plea to accept payment and the response was a polite but firm ‘ennaal mudiyaathu, sir’ (I cannot, sir). I left the shop without paying her.

Now, I am sure that a lot of doctors would have faced this very peculiar situation. I personally find this quite embarrassing as­ i am, in effect, accepting personal favors in return of services rendered as part of my duty as a government servant. Ethical codes for medical practitioners and the service rules of a government servant explicitly prohibit this. But this was just one among a series of similar situations in which i have found myself in, like many other doctors like me do.

There was this Punjabi farmer who barged into the dialysis room of our hospital, where I received my Nephrology training, carrying a big sack on his head. The sack must have been atleast 20Kg and he placed it at the entrance of the dialysis room where the staff nurse had stopped him. “Yeh kya hai?” (“What is this?”) the nurse barked at him. And his indignant reply was “Chaaval, ji ­ doctor saab keliye”! (Rice, {respectfully} for Doctor sahib!). The nurse’s eyes popped out and she started laughing, and every one else also joined in. It seems his young son was recently hospitalized with us with kidney failure following snake bite, he was on dialysis treatment for few weeks but made a complete recovery and had been discharged few days back. His father, a farmer, went home, packed some rice he had cultivated on his land and brought it for the doctors who cared for him, since he knew that they will not accept money! We were more amused than upset with this. Myself and my colleague, who were the senior residents working in dialysis unit then, tried convincing him that we accept neither money, nor gifts for treating patients and we were well paid for by the government for caring for them. The well-­meaning guy did not want to listen to any of these and instead tried convincing us that he was not giving ‘riswat’ (bribe) and he felt really bad that he could not repay the efforts doctors on duty took to save his son. He reminded us that his son was taken up for dialysis in the dead of the night and doctors and other staff had stayed awake to treat him, when the family feared for his life. He became emotional talking about his son and declared that there was no question of him taking back the rice and he could not think of anything else to gift the doctors with. With these words he thanked everyone and left the dialysis room, leaving us all wondering what to do with the sack of rice!

There were other patients who were equally keen on ‘giving back’ to the doctor who cared for them, but were more sophisticated than the innocent and well meaning Punjabi farmer.

There was this gentleman from somewhere near Manali who came with kidney failure. He was initially seen elsewhere and told to have permanent kidney failure and started on dialysis. Since dialysis is a life long treatment which is exorbitantly expensive, he thought it better to seek second opinion and also wanted to continue dialysis from our hospital since this will enable him to claim reimbursement. He got admitted in the Nephrology ward. I was the senior resident in charge of that ward at that time. After listening to him and going through his reports I felt that what he had was not End Stage Renal Disease (ESRD -­ permanent kidney failure) and I went to my professor and discussed the case. We did a kidney biopsy and having found his disease to be treatable and ­ possibly ­ curable, we started him on some medicines, while continuing dialysis. Within a period of about 6 weeks his kidney function had improved to near normal levels and we discontinued dialysis and removed the permanent dialysis catheter that was placed in his abdomen for doing peritoneal dialysis. He could not suppress his happiness and was bewildered at the unexpected and pleasant turn of events. He had resigned himself to the fate of remaining on dialysis for the rest of his life with its attendant problems; and here, in a matter of few weeks, he found his kidney function returning to near normal and himself being ‘liberated’ from dialysis!

The senior resident is often the most ‘visible’ person in the treating team in hospitals like ours’ and for most patients he is ‘the’ doctor who treat them and whom they are most comfortable with. This man was a well educated central government employee and he did not hesitate in expressing his gratefulness to the hospital and the doctors who took care of him. On the day of his discharge he asked me whether i have been to Manali or not. Knowing very well the direction in which the conversation is going to go, i told him a lie ‘mujhse sardi bardaas nahi hoti’ (I can’t stand cold weather). He refused to believe this because winter was pretty harsh in Chandigarh also and at the peak of winter, temperature dip below zero degrees in Chandigarh. However, my answer made him curious and he asked where i am from, and exclaimed ‘aap madrasi hain?’ (are you a madrasi?) upon my reply. He did not mean any insult, neither was any taken. He told me that Manali is a very beautiful place to visit and handed me a piece of paper with his address and contact details including phone numbers and added that if I ever came to Manali I should inform him and allow him to meet me there. I made a mental note to throw away the paper promptly after he left.

But it turned out that I had underestimated him. Many months passed, Deepavali went by, and winter started setting in. The gentleman from Manali came for follow up visit to the hospital and having not found me in the OP clinic, he searched me out in the dialysis unit. He just wanted to say hello and thanks once again, since he will not be able to travel to Chandigarh for many months now, due to winter and snow setting in at Manali. I was relieved, since he did not bring up the subject of Manali visit again; but not for long. The next day morning, the peritoneal dialysis coordinator in our dept came to me with a small packet, which the gentleman and his wife had left with him, with instructions to hand it over to me in person. He asked me to open it and take a look. They were a pair of beautiful, colorful, home made woollen socks. The gentleman’s wife had hand-­knit them specially for the madrasi doctor who could not tolerate the harsh North Indian winter!

This time i did not protest; anyway, the ‘offender’ was not around to hear, even if i protested.

Now, tell me, what a doctor should do in situations like this? If you accept the gift, are you doing the right thing? Are you not breaking rules? Am i not lowering my moral standards by accepting personal gifts?

And what are we doing by refusing? A well meaning, innocent person, blissfully unaware of rules and medical etiquette but eminently pleased by the services he received, sometimes life saving / life changing, thinks of some ‘harmless’ gift for the doctor out of love, more than respect. I have tried putting myself in his position. What will i feel if the doctor says he will not accept my gift? Am I likely to feel belittled by the doctor? Will i understand why the doctor is refusing to accept my simple gesture of love and respect, which i think i owe him?

I am searching for an answer ­ you can help me out, if you can find any!

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Originally published in JIPMER Montage 2014 — The annual college magazine published by JIPMER, Pondicherry, India