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This chapter examines national parallels to the local ethnography and the impact of the national crisis in malpractice and obstetrical care on the specialties of obstetrics and family medicine. The research texts for the national story are drawn from the medical specialty literature of the period. During the 1980s, obstetricians throughout the country protested the rising costs of medical liability premiums; physicians went on strike, withdrew from practice, and questioned the unprecedented rise in malpractice claims. Fears confined to the specialty of obstetrics. However, as in Coast Community, the tensions created by malpractice claims quickly spilled over to affect obstetrical care offered by family physicians and nurse-midwives.

Consider the following advice given to parents whose children are dying in hospitals: “If your child has to die, he can die peacefully. You can make sure he is free of pain. You can make sure that everyone has a chance to say good-bye” (Hilden & Tobin, 2003, p. 3). To offer parents this kind of unconditional assurance (i.e., “You can make sure . . . ”) dismisses the confusing and disturbing realities of actually having to care for a child when it becomes increasingly apparent that curative intent is failing and staff begin to question how best to proceed. The complexity of symptom control in various clinical conditions sometimes precludes children from having peaceful deaths. However, when you read findings from the few palliative care studies that exist (and there are few that consider children as participants), issues of pain management and psychosocial support at the end of life do not seem to be so difficult to resolve. These findings promote ideas that, when satisfactory end-of-life care is not achieved, it is because mistakes were made, staff were inadequately trained, and children thereby were made to suffer unnecessarily. Such ways of thinking in turn lead bereft parents to feel guilty at not having empowered themselves to have taken greater control in the care of their child and to have done the right thing for their child. Although mistakes occur, staff can be better trained, and children might unnecessarily suffer, there are very few guarantees of a comfortable way of dying from medical causes. Most textbooks and studies about end-of-life care simply ignore the messy realities and uncertainties, particularly as they pertain to children and their families. The Report to the Board of Directors of the American Psychological Association from its Working Group on Assisted Suicide and End-of-Life Decisions (2003) raised a clarion call to document publicly what it is like, in practical day-by-day terms, for people who die in hospitals and how it affects endof- life decisions for the staff, patients, and families. We all prefer to die quickly, without protracted suffering and pain and without humiliation. Deaths during sleep are particularly preferred.

Medical education in India is not sufficiently oriented to the health care needs of the country. The knowledge of medicine has primarily originated in western countries and there are mismatches between medical knowledge and health care problems on the ground in India. While specialties such as cardiology and thoracic surgery have grown, basic treatment of coronary artery disease is not accessible to the majority of people. Medial colleges are also not adequately linked to the health care system, therefore not optimally effective in improving health care delivery and exposing students to all levels of the health system. Addressing these structural problems may involve making medical colleges responsible for health care of geographic areas, development of primary care education, and medical curricula that engage with the local context.