REMEMBERING THE HUMANITARIAN SIDE OF MEDICINE

Menghadap Paduka Seri Ayahanda

Duli Yang Maha Mulia Sultan Azlan Muhibbuddin Shah

Ampun Tuanku

Sembah Anakanda mohon diampun.

Adapun Anakanda bersyukur ke hadrat ILAHI kerana dengan limpah rahmat dan izin dariNya jua, Paduka Seri Ayahanda dapat berangkat ke Majlis 4^th ASEAN Conference in Primary Healthcare ini. Sesungguhnya keberangkatan Paduka Seri Ayahanda telah meningkatkan lagi darjat dan seri Majlis ini.

Dipohonkan limpah perkenan Paduka Seri Ayahanda untuk membolehkan anakanda memenuhi hasrat penganjur untuk menzahirkan titah utama sempena pelancaran “Ucapjasa Sultan Azlan Shah” pada pagi ini.

Ampun Tuanku

1. I am pleased to be here to address such an eminent gathering of medical professionals. I am particularly pleased for another more personal reason. It is a special privilege for me to have been invited to deliver this Inaugural Oration in honour of the illustrious personage who is my father – Duli Yang Maha Mulia Paduka Seri Sultan Azlan Shah.
2. The theme of this morning’s Address is a concern for humanity and the humanitarian side of your profession. It could not be more apposite as a fitting tribute to a man revered throughout his reign, as Sultan of this State of Perak and as the Ninth King of Malaysia, for his unstinting care and concern for the welfare and the well being of his subjects.
3. It is a topic pertinent in another way. Duli Yang Maha Mulia Paduka Seri Sultan Azlan Shah had an illustrious career in the Law and came to occupy a position of great eminence at the head of the Judiciary as Lord President. His Royal Highness was in his time a great jurist whose judgements made a definitive contribution to the development of Malaysian jurisprudence. His Royal Highness’s published works remain a point of reference to this day. His Royal Highness brought distinction to the Bench, and in particular lived up to the title of Chief Justice since his whole career was dedicated not just to the Rule of Law but to the cause of Justice that informs it. Again this resonates with the theme chosen in His Royal Highness’s honour. His Royal Highness achieved distinction in the legal profession.
4. As his son, I have immeasurable respect and admiration for my father and more gratitude than I could ever express. Life principles that my father imparted have been invaluable in shaping my own values and character.
5. In the modern world, professions proliferate. But originally there were only three – the “Learned Professions” of Divinity, Law and Medicine. All were based on advanced learning. In all three we can distinguish between the body of knowledge upon which they were based, which is generic – and the practice, or the way the knowledge is applied to humanity and this can vary.
6. Thus, just as Law, as exemplified by my distinguished father, is a discipline that serves the ultimate purpose of Justice, so Medicine, a branch of learning with a strict code of conduct, is subject to a moral purpose. The power to heal serves a humanitarian end in caring for people, in compassion and in mercy.

Ladies and Gentlemen

1. I must be candid. My own perspective is that of the layman, an occasional patient and a frequent observer. I have neither the intention, nor would I presume to intrude on your professionalism and your specialist knowledge and skill. You are masters of your trade, which will be given the respect it deserves, implicit in all I have to say. I shall be confining myself to the sphere of medical practice where our two worlds meet – a subject central to you and very close to my heart – a concern for humanity. Beyond technical proficiency there is a humanitarian dimension interwoven and indissolvably linked to your professional calling.
2. The members of this audience are no strangers to this. It goes back to the distant origins of medicine. The title of this talk begins with the word “Remembering”. If we go back to ancient times, medicine could not yet be considered a science. But even if it did not have the developed knowledge and skills it may claim today, it did have from the outset its own integrity. Healing was then perceived as a service to humanity predicated on a belief in harmony. This will be readily understood by our Chinese compatriots because of their belief in their own traditional philosophy of harmony – in this case based on the balance of heaven, earth and the “middle Kingdom” i.e. man. Medicine in the Middle Ages was a means of restoring wholeness by harmonizing the body, the emotions, the mind and the spirit. In many ancient cultures the shaman and the medicine man was both priest and healer, assigned to care for people by ministering to both their physical and their spiritual needs. There was no dichotomy between the sustenance of the body and the sustenance of the spirit.
3. I believe modern conventional medicine should be seen not as an impersonal science, but as a service that employs science.
4. In the old days the human face of medicine was probably more visible as doctors were more integrated in the community – never failing to present themselves when summoned – on foot, on bicycles, by public transport if need be. These instinctive humanitarians became almost demi-Gods, accorded a place of respect and often prominence in society.
5. The dichotomy that currently exists between the sciences and the humanities has occurred because the dominance of science, in subsequent times, and particularly during this century, has tilted the balance. The intellectual split between the two was the consequence of a search for certainty and universality of knowledge as a basis for social order. The removal of the sciences from overt religious and political control had as one consequence the unprecedented growth in the understanding of human biology and in the application of this knowledge to medicine. Moreover, this split between the sciences and the humanities has altered the relationship between patient and physician, and between the medical profession and the public. A scientific world infused with professional norms, procedures, priorities, and standards is perceived as incompatible with a humanistic world suffused with fears, hopes, opinions, and values.
6. The dominance of science has inadvertently produced modern medical professionals who are more and more conditioned to function as fixers (instead of healers). A physician must know about diseases in general and be able to classify diseases according to their etiologies, symptoms and signs, pathophysiologies, and natural histories. The accuracy of the diagnosis and the certainty of the prognosis influence the effectiveness of any remedy a physician may prescribe to achieve a cure. The dilemma is this: modern medicine relies on medical expertise, physician experience and good judgement to fix physical problems by focusing on these symptoms and signs. And by focusing on mainly physical symptoms and signs, there is a risk of detachment from the personal and human aspects.
7. The medical fraternity, secure in its exclusive, scientific enclave where even the language it uses is inexplicable to the patient, does not always connect to the wider world. A study conducted in the United Kingdom found that one of the common complaints by patients is the lack explanation or communication by doctors. Which is interesting as this has nothing whatsoever to do with the treatment outcome! A compassionate communicator acknowledges emotions of fear or despondence and encourages patients to express their concerns and anxieties. He or she approaches all patients in the caring considerate manner that is no more than a reflection of his or her own nature.
8. When patients are asked why they like their doctor, it is common to hear responses such as: “He cares”. “He has good bedside manners”. We want to be treated by doctors who care. Understanding and dealing with the emotions of patients are part of the challenge that physicians must accept.
9. In many countries around our region and our globe, we face the scarcity of manpower in the healthcare sector – especially where healthcare is publicly funded. In the case of Malaysia, we have come a long way since Independence yet we are saddled with a shortage of medical professionals and a mal-distribution of healthcare practitioners. Our nation has attempted to ease the situation by establishing more medical schools in the country. By the end of 2003, we had over eighteen thousand doctors practising in the country, 54 percent of them in the public sector. This gives a doctor to population ratio of one to one thousand four hundred (1:1,400); which while pointing to an ascending trend, is still short of the norm for developed countries of one to eight hundred (1:800).
10. The geographical mal-distribution of doctors is more worrying. We have states like Kelantan, Terengganu, Sarawak and Sabah with doctor to population ratios of one to more than two thousand (1:2,000). Even when they make it to the outpatient room it is common to see large crowds of patients – from infants to the elderly – waiting for hours to see a physician. Often, they can only be afforded a five-minute consultation. And doctors are sadly overworked.
11. Both healthcare professionals and the public lament what appears at times to be a certain dehumanization of conventional medical care. Even genuinely caring people can become distracted and preoccupied. The art of listening to the patient is sadly curtailed which leads to a concentration on the physical symptoms and prompt, standardized diagnoses. Doctors work under the intense pressures of information overload, departmentalization, bureaucratization and mechanization in medical practice compounded by financial pressures. Doctors (and nurses) may be restricted not only in the units of time afforded per patient but in a more restricted range of treatments readily and conveniently available.
12. However unfairly or indiscriminately, doctors are oftentimes accused of treating diseases or “cases” instead of treating people.
13. But I believe healthcare naturally attracts caring people. However intoxicated one may become with technology and all the exciting and absorbing advances in the science of Medicine, it is still a vocation based on the desire to serve one’s fellow men. A vocation is a higher, nobler calling than just a career. After all, the oath you have all taken binds you to an outstanding code of ethics. It preceded by centuries the corporate governance of which so much is made today. Hypocrites, the Greek physician, the Father of Medicine, was in fact a priest physician of the Asclepiclae fraternity.
14. Asclepius was the God of Medicine and Healing. He was the son of Apollo. His daughter, Hygeia, from whom we no doubt got the word “hygiene”, was the Goddess of Health.
15. Their legacy includes the humanitarian aspect – a devotion to humanity as a whole. Healing is linked to the place of compassion in our lives. The Seven Works of Men are interlinked, of which the first is “To tend the sick” followed by “to feed the hungry” and “to clothe the naked”.
16. Medicine is a science but the practice of medicine is an art. Technical proficiency and scientific knowledge are the body of your profession. Caring and compassion for one’s fellowmen are the soul.
17. While the original purpose of medicine is to heal, doctors as healers have made way to doctors as fixers. Wherever this has occurred it now needs reversal. The sciences are and must be subservient to human values. Fixing or curing happens at the level of the body and requires expertise, but healing happens at the level of the whole person – the body, the mind and the spirit. It is not the outcome of and interaction between an expert and a problem, but rather it is the outcome of a relationship between human beings whose combined potential brings forth more effective and holistic healing power – even if the illness is not cured. Many things that cannot be cured can still heal – a person may grow in ways where the wound of an illness becomes a smaller and smaller part of the sum of life.
18. Restoring humanity in medical practice is our challenge. It offers a chance for healthcare to reclaim its original meaning and purpose and by doing so restore any inadvertent loss in integrity. Organisations such as the American Medical Association, the Association of Integrative Medicine and the Singapore Medical Association’s Centre for Medical Ethics and Professionalism are today becoming more and more dedicated to the practice and propagation of humanistic medicine within medical practice.
19. It is commonplace these days to speak of medicine as a business. We know that healthcare is a commodity where consumer demand outweighs supply. As our society becomes increasingly sophisticated, consumer demand for healthcare rises, resulting in a corresponding price uptrend. Furthermore, factors such as high costs of drugs, devices, treatments and testing, as well as the immense expense involved in years of medical school have put an increasing price-tag on medical services.
20. The pharmaceutical industry is one area where commercial considerations often come into conflict with humanitarian concerns. Today only 10 percent of health research is devoted to diseases that account for 90 percent of the global disease burden. These are diseases that occur primarily in the more underdeveloped parts of the world. Developing treatment for diseases like malaria, sleeping sickness and tuberculosis is an unprofitable venture for multinational companies. Consequently, medicines against tropical diseases account for a mere 1 percent of new drug patents. Even when cures are available, high prices put these drugs beyond the reach of the majority of the disease’s victims worldwide.
21. In focusing on research at the top end of the market, pharmaceutical companies are merely responding to the incentives of the marketplace. Given the huge investments and uncertain outcomes, it is difficult for public companies to justify to shareholders spending millions on products for which there is little prospect for return.
22. From a humanitarian perspective, it is unacceptable that so little research has been devoted to vaccines or cures for diseases that kill millions each year in poor countries, while vast sums are spent on producing drugs to fight baldness and erectile dysfunction. From a public policy perspective, such market failures argue for a greater role for the public sector. I am happy to note that a new initiative known as the Drugs for Neglected Diseases Initiative has been formed to undertake drug development for neglected diseases such as malaria. I congratulate the six founding members – Medecins Sans Frontiers, Indian Council of Medical Research, The Institute Pasture, The Kenya Medical Research Institute, The Oswald Cruz Foundation and the Ministry of Health, Malaysia – for taking this initiative.
23. There is, in reality, nothing inconsistent about being both a noble profession and a business. In one way or another, everyone is an entrepreneur, some more so than others. Yet professionalism finds a comfortable home between the two extremes of medical service. At one end we have the saintly altruistic missionaries whose calling must surely come from a higher power. At the other extreme, the motivation can be purely commercial. The medical profession is one in which one does well by doing well for others. Professionalism thrives so long as one is mindful of the need to put the patient first and so long as one is also mindful of the perils of greed.
24. Clinical practice should always operate within the guidance of ethics and the law. At times certain difficult decisions have to be made. Should a patient’s HIV status be disclosed to his or her partner? Should a patient’s psychiatric or alcoholic history be made known to a prospective employer? Should euthanasia be practiced at all? Should we determine a child’s gender or even dabble in cloning? Science alone is not equipped to resolve these difficult moral questions. We need the humanities to guide us towards a solution.
25. I do not believe that compassion need be constrained by time. It need not be sacrificed because the physician has only five minutes with a patient. Our compassion allows us to share the human experience. We must always be mindful that everyone has a story, and likewise every patient has a story outside his or her present symptoms, and try to allow for this in the consultation.
26. How do we foster a more compassionate approach to medical practice? How do we perpetuate a progeny of professionals who will always put the patient first? For compassion to be instilled within the medical practice, responsibility lies with the faculty who train new doctors. But can compassion be taught? There is an undoubted link between compassion and medical practice but one distinct difference I see between teaching the two is that while most new medical students will not have in-depth understanding of ‘cardiology’ or a strong grasp of ‘bacteriology’, a good number would have intrinsic appreciation of compassion, kindness and self-sacrifice from learning it early in life through the positive influence of parents, teachers and religious leaders.
27. So the question then is not if compassion can be taught in medical school but does medical school give due emphasis to the integration of the art and science of medicine in its curriculum? While embracing new developments in medical research, the latest scientific breakthroughs and modern technology in delivering healthcare services, we must never lose touch with humanity as the soul of the medical curriculum. A proper balance between the sciences and the humanities is necessary in preparing physicians to deliver balanced healthcare and in helping students develop a value theory of becoming people-oriented.
28. If we wish to have doctors who treat their work as a calling rather than a trade, then medical education must be structured to promote a consciousness among physicians of their social responsibility. Medical school admissions committees should look more closely for evidence of altruistic behaviour in the applicant such as volunteer work in aid organisations or hospice and other indicators of community service.
29. It is not that we are without inspiration. There are many examples of humanitarianism in the medical profession beyond the call of duty. Many of the missionaries who work in Africa are medical missionaries. Others answer the call of suffering and are fighting the insuperable battle against AIDS in that medically beleaguered continent. Malaysia sent its medical relief teams to Bosnia, followed by the Mercy missions. Opposed as we are to military conflict as the solution to Iraq we nevertheless are not turning our backs on the plight of the Iraqis. Malaysia’s “military” contingent will be a medical militia.
30. And lately we have had the most heartrending example of all. The recent Tsunami. This terrible tragedy proved also to be a triumph of humanitarianism. Doctors again became Front Line troops. The devastation inflicted on so many of our fellow human beings united the whole of humanity in compassion. The Tsunami sparked a Coalition of the Giving as disaster relief funds poured in from all parts of the globe. It showed the universality of compassion.
31. I recall the story of Ahmad and Muhammad Rosli – two lives, two individuals conjoined at the torso – born to a family financially incapable of undertaking the costs of separation surgery. In 2002, their family’s cry for help crossed national borders. Assistance and support came in all forms and from all corners of the globe. Not least from the Crown Prince of Saudi Arabia who donated RM1.5 million for their operation at the King Fahd Hospital in Riyadh; a British couple from the Humanitarian Aid Project who looked after the boys while they were undergoing tests in the United Kingdom; and consultants at the Great Ormond Street Hospital who offered to donate their services to perform the surgery. Thanks to the ‘touch of humanity’ displayed by the international medical community and the general public, Ahmad and Muhammad Rosli safely and successfully underwent their surgery, and are today not only separate souls but two separate physical beings leading normal happy childhoods.
32. The story of Ahmad and Muhammad Rosli warms our hearts and offers a glimmer of hope for love and humanity to thrive in this world.

I’d like to end with a quotation from Sir Francis Bacon:-

Quote

“I hold every man debtor to his profession

Wherefore he should strive to be an ornament thereto”.

Unquote.

1. In closing, may I once again pay my respects to the one profession, above all others, which owes its whole existence to caring for others. And to those amongst you who are true ornaments of that profession.

We thank you.

Ampun Tuanku

Demikianlah ucap utama yang telah dapat anakanda sempurnakan . Anakanda menjunjung setinggi-tinggi kasih atas kesudian Paduka Seri Ayahanda untuk sama-sama mengikuti penzahiran titah tersebut.

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