By Manoj Viswanathan and Gopika I S 

A few weeks ago, Keerthi (name changed) - a bank employee in Kochi - had a harrowing time running from pillar to post to get the body of her father who succumbed to death after a prolonged stay in the Intensive Care Unit of a prominent hospital in Kochi released. The hospital authorities had withheld the body, demanding the kin to settle the hefty bill. Thanks to the intervention of politicians, Keerthi could get the body released after a day-long wait.

But she does not want to elaborate on the painful chapter in her life as the family is trying to put the past behind.

Not so in the case of Satheesh, who disclosed to Express the harrowing experience he went through when his father was undergoing treatment for cancer at a well-known hospital in Kochi. A resident of Perumbavoor, he owned a leather shop and operated a cab service with a fleet of 15 cars. His fortune took a turn for the worse after his father was admitted to a hospital following stomach pain. He was referred to a prominent hospital in Kochi where he was diagnosed with cancer. The hospital authorities told Satheesh his father can be cured through surgery. But after the surgery, his health deteriorated and he had to spend around two months in the ICU.

The hospital slapped a bill of Rs 19 lakh and Satheesh had to sell all his assets, including the leather shop and cab service, to meet the expenses. When he ran out of resources, the hospital authorities discharged his father, saying he was cured. However, two months after discharge, he passed away.

“It is sad I couldn’t save my father even after selling all my assets. When the hospital authorities understood that I have been reduced to penury, they shifted my father from the ICU to the ward and later discharged him claiming he has been cured. I met many people who had similar stories to share while waiting outside the ICU. Medical care has become more a business than a service,” said Satheesh.

Karim (name changed), a native of Thalassery, was admitted to a prominent hospital in Ernakulam for cancer treatment. His sons, who were small-scale traders, had to sell all their assets to meet the treatment cost. When Karim breathed his last, the pending amount was Rs 1.5 lakh. The hospital authorities said the body can be released only if the bill was settled. As the family had run out of resources, the Mahallu committee pitched in and the money was raised with the help of generous souls.

Indian Medical Association (IMA) ethics committee former chairman Dr Mohammed Ali said it is the hospital authorities' responsibility to brief the relatives of the patient about the treatment expenses and the chances of survival. "It is unethical to keep terminally ill patients alive with ventilator support and charge huge amounts as treatment cost. Doctors should leave the choice to the relatives. Giving hope of survival and making relatives pay hefty charges are unacceptable," he said.

Ali was removed from the chairmanship of IMA Ethics Committee as he protested watering down his report on kidney sale rackets operating in the state.

Refuting allegations of exploiting critically ill patients, IMA past president Dr Srijith N Kumar said some people are trying to spread rumours against the hospitals and create panic in the society. “The relatives of the patients sign a document giving consent to the treatment before performing a surgery. Ventilators help to revive patients in critical conditions. Actually, it is very difficult to get ventilators at hospitals,” he said.

Supreme Court lawyer Kaleeswaram Raj feels a 'medical ombudsman' would help improve the patient care and keep a check on all the possible violations. "A medical ombudsman in the Centre with branches in all states as the procedures will be slightly liberal, more accommodative and will be more accessible to the general public. One should ensure this ombudsman is given adequate power. They need more than the recommendation power in such cases to issue directions and to implement these directions," he said.

In a landmark verdict, the Supreme Court on March 9, 2018, recognised the right to die with dignity and legalised passive euthanasia. The verdict lays down a broad legal framework for protecting the dignity of a terminally ill patient with no hope of recovery. The court held that “Accelerating the process of death for reducing the period of suffering constitutes a right to live with dignity.”

“As social workers, we often encounter situations where hospitals withhold bodies to force the relatives to pay the bills. Many families have been reduced to penury due to exorbitant end-of-life medical care bills. Even in cases of medical negligence, the relatives can’t win a case against the hospitals as a medical board has to probe the allegations. The medical board members will be members of the Indian Medical Association and chances of a fair trial are slim,” said CPM senior leader and former MLA Simon Britto.

P Rajeev, Ex-MP and CPM leader, confirms such things happen. "I myself deal with a lot of such cases every week. We talk to the hospitals and sometimes they give some leeway. Dr Atul Gawande had asked the doctor professionals in his book 'Being Mortal: Medicine and What Matters in the End' if they would prefer an end like the one their patients meet in the ICUs. The question becomes relevant as we move forward. We should also focus on strengthening our public healthcare sector," he said.

"We deal with this on a regular basis. A lot of people come to us for mediation. There should be some governing body to ensure patients are not exploited," said Hibi Eden MLA.

“When you are told the life of a blood relative is in danger, you panic and will do anything to save them. The doctors will say there is a 25 per cent chance of survival if an expensive procedure is done. Naturally, the relatives will pin hopes on the procedure ignoring the fact that it has a 75 per cent chance of failure. After battling death for days, the patient will die and the hospital will slap a hefty bill on the relatives. It’s all business for them. Compassion goes for a toss and they even hold the body hostage to ensure payment,” said a social worker.

The reality is cruel and inhumane. The hefty bills and the related coercions are a matter of fact. The release of a body is blocked as the hospitals do not have any other means to ensure payment. There are some practical steps that can be taken, including creating the post of medical social workers. Medical social workers are people who act as a liaison between the management, doctors and the patients. They can address the issues related to procedures, payments and the chances of survival with the patient’s family, ensuring they know what sort of a bill can be expected. Advice to move to a more affordable hospital can also be given before the patient’s health condition worsens," said a doctor.

Relatives of critically ill patients often complain after days of fear, frustration, stress and struggle to stay afloat with ventilator support, the patient sinks into an agonising death. And they are handed a hefty bill.

The story of 54-year-old Noushad (name changed) unveils the lackadaisical attitude of healthcare institutions. He was admitted to a city hospital due to complications resulting from a bariatric surgery performed a few years ago. He was taken to the hospital after he stopped eating. Though the doctors deemed him healthy and decided to discharge him, Noushad requested the doctors to conduct a diagnosis as he was not feeling well. After a few days, he was sent home.

Within a week his condition deteriorated and he was rushed to the same hospital. He was admitted to the ICU. After four days of numerous treatments and ‘new diagnosis' he passed away and the bereaved family was slapped with a whopping bill of Rs 13 lakh.

“After admitting him, we were informed he had liver cirrhosis and his kidneys were failing, something they did not see in prior tests in the same hospital," said his sister Ayesha (name changed). “On further inquiry, they changed their stance saying there were ‘chances’ of liver cirrhosis. He was given very expensive injections and dialysis and was even kept in the ventilator for some period. When we were let in his body was barely moving. Everything seemed fishy and we raised the issue with the duty doctor, who, we found, was not aware of the history of the patient,” she said.

"I have encountered the sin of gluttony in medical profession twice," says Anil (name changed), a resident of Kollam. Once, a critically ill relative of his suffering from liver cirrhosis was admitted to the ICU of a well-known hospital. The doctors there said the patient was kept under observation for 48 hours. Though the hospital authorities denied permission, his wife forcefully entered the ICU only to see the lifeless body of her husband.

On the other occasion, a friend was taken to a hospital after having sustained injuries in an accident. The hospital authorities said he was suffering from cerebral haemorrhage. But when he was taken to another hospital, it was found he had suffered only an injury to the nose.

Doctors have targets

Hospitals these days are run by corporate houses. A doctor working with one such private hospital asserts that it happens. “They have business plans and like any other job, the performance of doctors is evaluated every month. They are forced to prescribe unwanted tests. At times, things come to light only when the insurance agencies refuse to pay for the procedures,” said the doctor.

Let’s look at a group running a chain of hospitals in Kerala. The group's managing director and his wife make regular visits to all their hospitals with a power point presentation highlighting the ‘conversion rate’ of each doctor. "It is the number of outpatients-turned-in patients and later admitted in the ICU and prescribed expensive tests by each doctor. The whole chart is shown and it is an irony the doctors are forced to bow their heads because they have a low conversion rate,” said a doctor who once worked with the institution.

The conversion rate is one coinage. Names may change but the practice exists in almost all major hospitals.

So, has corporatisation led to the deterioration of moral values in the healthcare sector? Are hospitals following unethical practices to exploit the hopes and anxieties of relatives of terminally ill patients to make quick money?

“Earlier, doctors used to think about what could be done to save a patient. But the corporate culture has brought in an attitudinal change," said a senior surgeon.

"Now, corporate hospitals give targets to doctors. Every 15 days, they hold assessment meetings where the performance of the doctors is evaluated through a power point presentation. The criteria obviously are how many tests, scans and surgeries a doctor has prescribed. Doctors drawing hefty salaries are always under pressure. Medical ethics has given way to profiteering,” the surgeon said. That doctors prescribe expensive tests is a fact. But foolproof case sheets make it difficult to prove a case against them.

Lack of medical auditing provides hospitals with an opportunity to exploit patients, said naturopath Jacob Vadakkanchery. “Western countries conduct medical auditing to make the hospitals accountable. They have to furnish details like why the patient is admitted and what treatment is provided. There are many hospitals that give a glimmer of hope to the relatives and squeeze money out of them,” he said.

A doctor at a corporate hospital was repeatedly harassed by the managerial staff asking him to prescribe more tests. He had to resign due to the pressure. Though there are laws banning clinical trials on human beings, many hospitals continue it, said Jacob.

Medical negligence: A tough fight

Activist K Venu who launched 'Chikitsa Neethi', an NGO to help patients fight cases against hospitals for medical negligence, said there was little awareness about CrPC medical law. "We are fighting a case of medical negligence in the High Court now. Many patients approach us alleging exploitation by hospitals. Even if a person comes forward, a medical board has to appraise the court regarding the legality of the case. In our experience, the medical board is always influenced by the IMA. Now, we have formed a panel of doctors who will help the patients in genuine cases," he said.

They prefer dignity in death

At a time when allegations fly thick and fast about corporate hospitals emotionally blackmailing relatives of critically ill patients, the right of such patients to choose a natural death is being debated.

Writer and critic M K Sanu says he prefers a dignified death at home in the presence of loved ones to the chilling final moments amidst beeping machines in an ICU.

"I don't want to be confined to bed and be a burden to my family. I have seen my friends bedridden for over two years and the families struggling through it. I want my family to let me go if that's the case with me," he said.

Entrepreneur and philanthropist Kochouseph Chittilapilly says, "It is a person's right to die with dignity. I have been arguing for the right to die peacefully and gracefully. I have also made a will. Now I am healthy. No one knows what might happen to me in the future. If I fall ill, my family would certainly take me to hospital. However, I don't want to die in an ICU. My grandparents have died peacefully in the safety of their home. I would prefer that or palliative care to the most," he said.