ETHICS OF THE �VIP SYNDROME� -

The Perils of Being a Very Important Patient

Dr. K.R. SETHURAMAN, MD, PGDHE,

(Formerly) Professor of Medicine, JIPMER, Pondicherry-605006

INTRODUCTION

The ethical implications of treating a VIP -a Very Important Patient- have recently acquired topicality due to the demise of a young minister and the media overkill of the knee surgery done on our prime minister. This article focuses on some ethical distortions in health care brought about by the �VIP syndrome� and suggests some remedial measure to ensure that the VIP gets quality care that is not distorted and excessive but appropriate and ethical.

NON-MALEFICENCE

Extreme obsession with non-maleficence is perhaps the first component of the VIP syndrome. Chagrin factor 1 -�What if my decision misfires?�- overrides all other considerations leading to over-investigation and empirical over-treatment of the VIP. At the same time, very effective and beneficial options may take a back seat if the inherent risk invokes chagrin factor. The net result is that harmless options are overused even if they are less effective. The quality of care is thus compromised.

The worst presentation of chagrin factor is when the professional decides that it is better to play safe than be sorry later and refers the VIP to some one else under some pretext. Many referrals of Indian VIPs to �higher centres� are due to such escapist washing-one's-hands-off-the-case. The VIPs are to be pitied rather than envied when they fall in to the trap of chagrin factor and travel around in search of effective care. A former Lt Governor of Pondicherry with multiple end-stage problems went to the USA only to return with advice for palliative care. If there were a professional at home bold enough to call a spade a spade, a lot of unnecessary travel and expenditure of taxpayers� funds could have been avoided.

EQUALITY

From an ethical viewpoint, this is the next major casualty of the VIP syndrome. To accommodate the VIP and his/her entourage, many alterations are made in the functioning and at times, even the structure of the health care facility. General patients, who are already in the hospital and their relatives, are put to a lot of inconvenience.

PATIENT AUTONOMY

While patient autonomy is to be fostered in all doctor-patient transactions, it has to be tempered by �judicious paternalism� especially if the patient's decisions are of questionable value, downright foolish or positively harmful. In the case of a VIP, most medical professionals may play the role of an uncritical �Nurturing Parent� and pander to all the whims and fancies of the VIP.

It takes an exceptionally bold and self confident professional to look in to the eyes of the VIP and say, �In my professional opinion, your decision is faulty, potentially harmful and not to be pursued.� Absence of such professional guidance renders the VIP vulnerable to less than optimum health care. A tragic example is a VIP with intermittent low-grade fever due to lymphoma, who was taking empirical anti-tuberculous therapy for several weeks until it was too late.

CONFIDENTIALITY

The intrusive media chant the mantra of �Public's right to know� and make a VIP's health problems highly visible. Pity the VIP who needs to have surgery of his rectum or prostate! All the gory details of the disease and all the steps of the proposed surgery will be laid bare in all the media including Internet. Most frightening, especially for the VIP�s well-wishers, are the details of what all could go wrong in the worst case scenario.

PROFESSIONALISM

Informed consent from a VIP is often distorted. For example, HIV testing is hardly ever done on a VIP. Pre-test counselling is tricky and painful for the doctor and may sound offensive to the VIP. The easiest way out is to ignore the harsh realities of the case and tread on safer grounds.

Even historical details like addictions, exposure to sexually transmitted disease, sexual orientation etc. may be skipped in the case of a VIP. There are special techniques of indirect questioning to elicit these2. However, most doctors are not trained in communication skills. Consequently, important diagnostic clues may be lost in the case of a VIP.

Health care Provider-seeker relationship is basically one of unequal power. The provider has professional knowledge and skills, which are sought by the patient for health care and relief.

This unequal power balance makes fiduciary relationship (one based on mutual trust) between the provider and seeker an ethical obligation. In the case of a VIP, the situation is often distorted. The all-powerful VIP condescends to let the care provider treat him. The doctor-patient relationship is distorted to that of a vendor-client type. The vendor pampers the VIP client and panders to his/her whims and fancies. The quality of health care is often compromised and below par 3.

DEATH AND DYING

For most VIPs, death is an orchestrated event. The time of officially declaring death may be several hours to a few days after the actual demise. The process of dying is invariably a prolonged one, even when it is undisputedly futile to continue treatment any further. A few years ago, the emperor of Japan, who was terminally ill with cancer that had spread all over, was put on life-support systems and pumped with litres and litres of blood to prolong the process of the final exit. In India, dead VIPs are put on heart lung machine and dialysis to try and �keep the body technically functioning,� until the time for disclosure of "death� is decided by non-medical power brokers.

CORRECTIVE STRATEGIES

It is obvious that VIP syndrome leads to several ethical compromises and impairs quality of health care. Generally, the VIP is to be pitied rather than envied. What could we do to improve matters?

All, especially the VIPs, should realise that VIP syndrome distorts health care and may compromise the quality of care.

A team of well-respected senior professionals may be nominated in each region of the country to handle VIPs ethically and without fear.

Empower and enable the professionals to treat a VIP with the same trust and professionalism as exhibited while they treat any other patient.

Foster fiduciary relationship between a VIP client and the team of professionals by keeping the intrusive media and power brokers out of the health care process.

Do not initiate high profile "witch hunting" whenever a VIP passes away or has an adverse outcome.

For the professionals in making, impart training on communicating and negotiating skills so that in future, medical professional are capable of handling the pressures of treating a VIP.

References

1. Feinstein AR: The 'chagrin factor' and qualitative decision analysis. Archives of Internal Medicine 1985 Jul;145(7):1257-9

2. K.R. Sethuraman: �Questioning Skills� in Doctor-Patient Communication. Jaypee Brothers, P.Box 7193, New Delhi. 110002 (In press)

3. K.R. Sethuraman: Trick or Treat - A survival guide to health care. EQUIP, P. Bag 8, Pondicherry-605006.