The physician’s agency

The physician’s agency

Vijay Gopichandran

An incident that happened in the clinic yesterday made me question whether I had any agency as a physician. In this blog, I am going to describe what I understand by the term ‘agency’ and my reflections on the agency of a physician. In philosophical terms ‘agency’ refers to the capacity of a person to act purely based on their free choice with some amount of awareness of their consequences. So, a person is said to have agency when they are autonomous, can act based on free will and take full responsibility for their choices. The individual agency works on two planes – social and moral. I am said to have social agency when within my work environment, I am able to exercise the free choice of treating my patients based on the resources available, the geographical location of the hospital, the type of patients who visit the clinic, the cultural and social norms and values of the clinic, etc. When the social circumstances grossly restrict my choices of treatment, then my social agency is compromised. On the other hand, moral agency is a totally different ballgame. It refers to whether I am free to make a moral choice. If I am faced by a moral dilemma and my moral compass gives me a choice of ‘right action’, do I have the freedom to perform that morally right action or am I restricted from performing it? This is my moral agency.

All human beings are capable of being complete and independent moral agents as each one is provided with an inner moral compass. However, there may be several limitations to people from active as truly independent moral agents. The policies of the hospital where I work may restrict my moral agency. Sometimes my social and moral agencies conflict with one another. From a social perspective, I may be acting as an independent agent when I take kickbacks (bribes) from diagnostic imaging centers for referring patients. Everyone else is doing it, it is the social norm. So I may not be able to refuse the kickback or protect my patient from the high cost of the diagnostic imaging (because of the kickback being added into the imaging fees). I may be forced to collect the kickback and return it to the same patient or cross-subsidize someone else’s imaging fee with that kickback money. By doing this, I am being a social agent who has the full freedom to do what he wants with the kickback, but not a moral agent, who should ideally work towards abolishing kickbacks.

Yesterday I saw a patient who made me question my social and moral agency as a physician. It was a man in his mid-thirties. He was drunk and completely inebriated. He had driven his motorbike under the influence of alcohol, his wheel skid and he had fallen. Fortunately, he had only minor abrasions over his palms, and both his knees. There was mild bleeding from the abrasions. Even as I was talking to another patient, this man barged into my room and shouted out, “doctor, get up, come here and see what has happened to me. I am bleeding and it is hurting”. The patient with whom I was talking and I, both of us were irritated by this intrusion. The patient, an elderly lady, started mumbling and telling me that such men under the influence of alcohol must not be allowed inside hospitals. I gently assuaged her and got up to take the man away from the room into the wound dressing and treatment area. He caught hold of my hand and literally pulled at me and started calling me names. I couldn’t understand what he was saying as his speech was slurred under the influence of alcohol. I think, my brain must have filtered out all the abusive words that he was uttering. I took him away to the examination room, quickly surveyed his injuries, confirmed for myself that there were no fractures of bones, no injury to the spine, that his pulse and BP were normal and walked back to the adjoining room where I was talking to the other patient. On my way back I told the man, “You have to wait now, I will attend to your injuries soon enough, but first I have to send the other patient with her prescription”. This made the guy angry and he tugged at the back of my kurta which I was wearing and pulled me.

I would usually not react to these kinds of acts. But that was not a usual day. The clinic and the clinic was extremely busy. It was already 2 PM and there seemed to be no respite in sight. So, I was pushed to my limits when he pulled me. My whole body was burning with rage and I wanted to thrash it out. But still I did not react, and with the same seething rage, I went and sat down in front of the elderly lady and resumed my work as though nothing had happened. I was pretending like nothing had happened, but I was burning in anger within. The man kept yelling and constantly shouting. He was disrupting my peace and my ability to see the patients. So, wanting to just put an end to the nonsense I went back to him and asked him what he wanted. He said he wanted immediate attention and wanted his abrasions to be dressed. I cleaned all his abrasions with normal saline and applied betadine ointment on them. He demanded that I do dressing with gauze pieces and tie it with a roller gauze. I knew well that the abrasions did not need dressing and they needed to be left open. But the man kept demanding and shouting. I gave in and dressed his wounds the way he demanded. When I returned to resume my clinic, I felt violated, taken advantage of and completely spent. On the way back home, I was reflecting on my own agency as a physician. Many times, as a physician, I have to compromise on what I know to be the best course of action and do the less optimal one, for the sake of peace. Sometimes I am made to do things that I know are not right, by unreasonable demands. Many times, I lack the social and moral agency as a physician. Then I realized that this is true in all nature of work. It was after several hours of these thoughts that I concluded that experience teaches you one thing in life, individual agency is a mirage. Any agency that a person has is limited to where it coincides with the agency of other people.