Business ethics of private general practitioners in KwaDukuza, KwaZulu-Natal

Background: Private general practitioners (GPs) have been criticised by the lay press citing unethical practice and the acceptance of kickbacks. In 2003, the Ethics Institute of South Africa conducted a national study of all doctors and also accused private GPs of unethical practice. In countries such as South Africa, with a practice of fee-for-service payments, there may be a temptation to put material interests above the best interests of patients. Private GPs, on the other hand, are of the opinion that the press and the Ethics Institute publication have unfairly singled them out. Objective: To detect whether private GPs in KwaDukuza perceive their colleagues to be practising ethically. Method: The study entailed a cross-sectional descriptive study design, in which all 30 private GPs based in KwaDukuza, KwaZulu-Natal, were asked to complete a self-administered questionnaire during 2003. The survey was done on a voluntary basis and anonymity and confidentiality was maintained. Results: Twenty-five doctors returned completed questionnaires (an 83.3% response rate). Seventy per cent perceived their peers to be practicing ethically, while 48% (12/25) reported that they did not observe any medical misconduct by their colleagues. The majority of the respondents (76%) reported that they did not know of any colleague who supplemented his or her income through the overservicing of patients. The majority of the respondents (84%) also reported that their colleagues never accepted cash payments that were not declared for income tax purposes. Medically unnecessary tests are a form of unethical behaviour pertaining to over-servicing, and 64% of the respondents reported that medically unnecessary tests to satisfy patient requests were not an important reason for performing these tests. The doctors expressed high stress levels from multiple stressors in their occupation. Conclusion: GPs in KwaDukuza indicated that they were under stress, but still practised ethically. The GPs emphasised the need for more training in medical ethics at all levels of the medical career. The majority of GPs of KwaDukuza perceive their colleagues to be practising ethically. Vol. 2 No. 1 Page 1 of 4 INTRODUCTION Private general practitioners (GPs) in South Africa have been criticised by the lay press of taking kickbacks and of unethical practice. The Ethics Institute of South Africa has added scientific influence to this accusation by carrying out a national study among all doctors1. The South African Revenue Service has used this information to target private practitioners. The findings of Landman and Mouton, who conducted the Ethics Institute’s study, show that two-thirds of doctors surveyed indicated that they have observed medical misconduct by a colleague.1 Two-thirds of the respondents in the survey indicated that doctors supplemented their income by over-servicing their patients. Over-servicing as an ethical misconduct occurs when doctors recommend or perform medically unnecessary tests to benefit the doctor financially. Paying a doctor for his or her professional services is sometimes viewed with resistance by society.2 The patient, the medical aid society and market factors all influence the remuneration of the doctor. Businessrelated issues also influence doctors in private practice. Doctors in private practice are faced with two competing interests: that of their ethical duties to their patients and that of the business interests of the practice.3 The rise of healthcare consumerism is seen to compromise the beneficence of the doctor-patient relationship.4 Some moralists argue that beneficence can be an effective means of cost control as well as a crucial component of the moral foundation of the medical profession.4 However, other South African doctors have pointed out that in today’s medical practice, bottom-line profit is crucial to the survival of a private practice.5,6,7 Hillier reports that in countries such as South Africa, with a practice of fee-for-service payments, there may be a temptation to put material interests above the best interests of patients.2 Private GPs feel they have been unfairly criticised. The ethical behaviour of doctors is a controversial issue. The researchers were interested in determining the perceptions of private GPs in KwaDukuza (formerly known as Stanger), of the ethical behaviour of their colleagues. At the time of the study, there were 31 GPs (including the researcher) in Kwadukuza, which is located on the north coast of KwaZulu-Natal.