Having three speakers today, coming from three different perspectives – the media, the medical profession and the public – may give the impression that the issue at hand is a three-cornered one.

I’d like to suggest that although today’s dialogue is three-way, it is not between three co-equal entities. There are really two main players under scrutiny – the medical profession and the media. Both are component parts of the larger whole, ie. society. Indeed, both exist for no other reason than to serve society.

What’s so special about the relationship between the medical profession and the media, that it deserves special attention?

I suspect that the relationship cannot be much different from, say, that between the government and media, the business sector and media, or for that matter, between the media and any organisation or individual having a reputation to preserve, or lose: the relationship is deemed "good" when the media makes us look good, and "bad" when it makes us look bad.

No one doubts the power and influence of the media. The need to "speak with care when on air" applies to everyone and the medical profession is not unique in this regard. Having said that, however, I can think of a few reasons why doctors are by and large, media-shy.

For a start, we are merely heeding Hippocrates’ admonition to turn away from the public eye:

"He must also keep a most careful watch over himself, and neither expose much of his person nor gossip to laymen, but say only what is absolutely necessary. For he realises that gossip may cause criticism of his treatment. He will do none at all of these things in a way that savours of fuss or of show."

Doctors have, through the ages, preferred to practice their art in relative secrecy than in full glare of publicity. This may have something to do with the sanctity of the doctor-patient relationship, but it probably has as much to do with preserving the power of the profession as well. ("Trust us – we know what we are doing").

If you think Hippocrates (circa 400 BC) is a little outdated, let’s look up the Singapore Medical Association’s Ethical Code (1996 Edition):

"Modern life brings the doctor into contact with the general public in numerous ways, both directly and indirectly, and raises for him problems of conduct unknown to his predecessors. The public interest in medical knowledge, the dissemination of medical information through radio and television, and the press interview, all demand the exercise of the utmost caution by the doctor, whose professional standards condemn self-advertisement and publicity."

- (Chapter VI – Relations with the general public)

But alas, the world around us changes. It’s been thirty years since the press (in 1968) invaded the operating theatre, riveting the whole world with details of the first human heart transplant and propelling Christian Barnard to instant fame. The modern media plays such a large, some might say intrusive, role in our lives, that there are no safe sanctums anymore.

The medical profession’s dilemma is that on the one hand, we have a code of ethics that frowns on publicity, yet on the other hand we cannot deny the legitimate right of the public to know. We also need the media to help us spread our messages on healthful behaviour. And not to forget, coverage of medical advances and spectacular breakthroughs can only enhance the profession’s own power and prestige.

Information is so readily available on the Internet these days that we cannot avoid having to deal with the media. Not a single day goes by without some report or other of the latest medical discovery by so-and-so, or some illnesses afflicting some famous personality, or some wonder drug in the pipeline. The medical profession has no choice but to learn to operate within the constraints of how the media works, while dealing with its own ethical concerns.

What might some of these ethical concerns be? I’d like to mention three, with respect to:

Consider the case of Htut Lin and Htut Win, conjoined twins who underwent separation at two-and-a-half years of age in Toronto in 1984. In an exclusive story entitled "Severing the Siamese Twins – from one life to two" LIFE Magazine showed pre-operative, intra-operative and post-operative photographs with no attempt to protect privacy. The surgical procedures involved intestinal, pelvic and genital separation and reconstruction.

"After consultation by phone with the parents…, the doctors agreed that Lin, the livelier and more aggressive (albeit smaller) of the two, should keep the male genitals. His sexuality is expected to be fully functional. During the surgery, the team constructed a vagina for Win from a tube-like section of the colon."

It might have been intended as a heart-warming story, but such "full disclosure" publicity on the children did not take into account how they might possibly, in later life, feel about the way their sex was assigned, or the fact that anyone can scan the back issues of LIFE on CD-ROM for detailed accounts of their genital re-constructions.

Whether it is separated Siamese twins, or test-tube babies, or HIV-positive blood donors, doctors often feel queasy about media reports that disclose the names of patients or bare to the world details of their medical conditions.

Another concern that doctors have is the raising of public expectations and false hopes that sometimes happens with sensational reporting of medical breakthroughs.

There is no denying that an informed public is in a far better position to make informed decisions about their health. The flip side is that a little knowledge can be a dangerous thing – it can generate unrealistic demands.

We must not forget there’s always a host of patients and activists out there with HIV infection, Alzheimer’s disease, cancer, and other conditions, regularly scouring the popular and electronic media in search of fresh leads and fresh hope. The financial world is equally alert to medical breakthroughs which may have enormous impact on pharmaceutical and biotechnology stocks – as seen in the phenomenal rise in Pfizers’ stocks when news of Viagra leaked.

Understandably, news reporters will always aim to be the first to break the news. But in the rush, accuracy sometimes suffers. Reporters may also, in their attempt to simplify information and make it more "digestible" to the average reader, unwittingly misrepresent facts. It would be desirable to double-check with sources, but the pressure of deadlines does not make that easy.

It is not just the media that is fiercely competitive. Premature announcements are sometimes not the fault of reporters, but of medical scientists eager for their research findings to make the headlines. We know that oral presentations at scientific meetings are not adequately peer-reviewed, but with all the pressures of competition out there, it may not be realistic to expect medical reporters to wait six months to a year for the article to appear in a medical journal, after having passed the rigorous peer review process.

How do we balance premature announcements which raise false expectations, against holding up information that could save lives or alleviate suffering? It is an issue we will continue to grapple with as the public demands to be better informed.

Self-advertisement – this touches a raw nerve of the medical profession. The SMA Code of Ethics states:

"… the publication of notices commending or directing attention to the practitioner’s professional skill, knowledge, services or qualifications… is discreditable to the profession of medicine and any registered medical practitioner who resorts to any such practice renders himself liable, on proof of the facts, to have his name erased from the register."

A footnote further elaborates:

"The ‘publication of notices’ referred to above includes publication of photographs and/or description or laudatory remarks of the practitioner’s clinic and/or its equipment in the lay press."

But once again, the world will not wait for us. Look up the Yellow Pages today and you’ll find notices unmistakably calling attention to the qualifications and services of medical specialists, complete with photographs, advertising their facilities – all within the new guidelines set by the Ministry of Health. I’m sure someone in SMA is working hard to bring about the necessary amendments to the SMA Ethical Code. But the key underlying principle of not allowing any doctor to gain "unfair professional advantage" over his colleagues – eg. through laudatory remarks about one’s special skills – is likely to remain unchanged.

What about the more subtle way of gaining attention through the giving of public lectures which may be covered by reporters? The SMA Code of Ethics concedes that "practitioners may properly place their view on medical subjects before the public" but cautions against doing so in such a way that it could be regarded as promoting one’s professional advantage. Furthermore, doctors are advised not to "discuss in the lay press controversial points of medical science and treatment", adding that "it would be more appropriate to discuss these in medical journals and professional societies".

It is interesting that we make a distinction between "lay" and "professional" press. But again, that may be how we wish to see things, but not all will necessarily agree with our view.

I have highlighted three dilemmas of the medical profession vis-à-vis the media, namely: privacy versus publicity, speed versus accuracy, and information versus advertisement.

I don’t have the answers, but I think it would be helpful to return to the paradigm I presented at the beginning, ie. that both the media and the medical profession exist in order to serve society. If we all keep in mind that the societal good is our common objective, we may be able to avoid or minimise some of the potential problems.

We mutually benefit by working closely together. The media is hungry on a daily basis for fresh and accurate medical content which the medical experts can supply. The media can communicate medical information to the public in a way that medical experts cannot.

This is not to say that the media’s role should be restricted to passive dissemination of information. Its additional role as the " Fourth Estate" – to raise issues in the public interest – is, in my opinion, quite proper and legitimate. The medical profession should welcome the media playing a provocateur role if that will bring about greater public accountability on our part. But I must stress that I’m talking here about a responsible media. Given the media’s penchant for controversy, there will be others whose experiences lead them to consider the term "responsible media" an oxymoron. They will therefore be less trusting and more guarded.

Finally, a word about the electronic media and its impact on patient empowerment. With the mass of medical information now readily available on the Internet, and the public now able to access Medline and order articles direct from medical journals, it is not inconceivable that some patients may well know more on any one particular topic than even their doctors. Not only does it put pressure on doctors to keep abreast, but it also radically alters the power-and-influence relationship between doctor and patient.

Some concern has been expressed about the qualifications of "cyberdocs" and the quality of the advice they give. A recent article in the Lancet (7th Nov 1998) addressed this issue. But there is no denying that many good websites exist too. Some are even peer-reviewed. I found a rather good one recently (drKoop.com) - it is targeted at the lay person and rides on the prestige and credibility of the high profile, former US Surgeon-General Everett Koop.

What I’ve tried to do today is to highlight some ethical concerns of the medical profession vis-à-vis the media.

That the medical profession’s ethical legacy and code of conduct continue to run counter to the contemporary role of the media may be the reason why we seem rather slow in coming to terms with the information age.

I believe we do need to move with the times. The fact that medical information – indeed, misinformation – can now be communicated so easily makes it all the more necessary for the medical profession to step forward to present its perspective so that society gets a more balanced view.