Every year a huge number of people in Ghana died unnecessarily or their health significantly maimed as a result of medical malpractices. Because no institution or individual keeps statistical records of medical malpractices in Ghana, most Ghanaians are uninformed about the magnitude of the problem. Therefore, there is a temptation to written off the problem as a figment of my imagination. However, narratives of victims or victims? representatives about medical malpractices are not only poignant, but also so obscene that one cannot easily write off this problem as insignificant, or accuse me of creating imaginary problems where there are none. Some Ghanaians are also likely to say that medical malpractices are isolated problems in the field and do not warrant a national attention. Again, the patterns of narratives of victims or victims? representatives demonstrate that medical malpractices are a systemic rather than a marginal national problem.

Nevertheless, a recent article in The New England Journal of Medicine, reports that more than 98,000 deaths occur every year in the United States as a result of medical errors. A simple logic tells me that if medical malpractices do occur in the United States that has well-trained doctors and access to high-tech medical technologies, how much less in Ghana where the healthcare system is poorly organized and severely underresourced. Thus, my sociological imagination tells me that medical malpractices in Ghana?s hospitals, health centres and clinics must be astronomically high.

The reader may ask this relevant question: How do you know that a medical practice is a malpractice? Before I answer that question, I would like to say that any country that does not have ?standards of best medical practices? is more likely to have more numerous cases of medical malpractices than a country that has established standards that are professionally and legally enforced. Standards of best practice serve as a guide to physicians regarding the procedures to follow to treat specific medical conditions, the therapy to prescribe for that condition, and the likely clinical or pathological side-effects. Nonetheless, it should be stressed that the development of standards of best practice does not happen in a vacuum; it happens where the professional medical body is well-organized and the government enforces existing regulations, updates existing regulations, or periodically regulates the medical profession.

In fact, my critical study of medical issues in Ghana and painstaking analysis of victims? experiences and/or those of their legal representatives have helped me to develop criteria that can be used to pinpoint medical malpractices. These criteria were developed after taking into consideration Ghana?s social, economic, and political circumstances, and the logistical constraints under which physicians practice their craft. A physician in Ghana should be guilty of professional malpractice in the following situations:

1) Making wrong diagnosis of illness, disease, or injury and prescribing wrong medication, treatment, or therapy;

2) Performing surgical operation without due care or a failure to follow proper professional procedures or rules generally accepted by the medical community;

3) Failure to inform the patient (or his or her parents, guardian, or legal representatives) of the side effects or risks of prescription medication, treatment, surgery, or any other therapies;

4) Failure to obtain the consent of the patient (or his or her parents, guardian, or legal representatives) before administering medication, treatment or performing surgery.

5) Using threats or undue pressure to obtain patient?s consent (or that of his or her parents, guardian, or legal representatives) in order to administer medication, treatment modality, or perform surgery.

6) Professing falsely to possess a specific medical skill and knowledge and as a result causing death or physical injury to people.

The punishment for these offences should include permanent or temporary suspension of licence to practice medicine, monetary fines, unqualified apologies, jail sentences, and monetary compensation to the victims or the victims? legal representatives. The fitting punishment for each offence would depend on the outcome of dialogue and discussion among the various stakeholders of the healthcare system.

Numerous narratives of victims or their parents, guardians or legal representatives indicate that such medical malpractices are common in Ghana. I will reproduce a few of these narratives for an illustrative purpose and also to support my view that medical malpractices are a serious social problem in Ghana.

1) Following cesarean-section surgery, a woman complained of difficulty in swallowing and excruciating pain in her throat. The doctor mistook the symptoms for a sore throat and administered a sore throat medicine to the patient. The patient died the next day from excessive aspirating vomit.

2) A boy age 4 sustained a few bruises on his right knee while playing with is friends in the school playground. Upon picking up the child from the school, the mother decided to take him to a clinic for treatment for fear that the bruises could be infected. Upon examining the bruises, the doctor treated them with disinfectant and also administered an injection to the child. Five minutes later, the child?s clinical and pathological conditions became progressively worse as his pulsating rate increased, sweated profusely, shook nervously, and started throwing-up. The mother out of fear asked the doctor what was going on. The doctor replied that it was the effects of the injection and that the effects would wane in a couple of hours. The child fell into comma and that was it. He was pronounced dead after 15 minutes.

3) A woman, who was 7 months pregnant, went on a regular check up at a government hospital. She told her doctor about constant pains in the lower part of her abdomen. In humility, she begged the doctor to operate on her and remove the baby. The doctor advised against that, saying that she had a few months to her due date. One day while she was having her shower, she felt a sharp gain in the same spot she had complained to the doctor. She started throwing-up and breeding intermittently from her private part. She was rushed to the same hospital and this time the doctor agreed to operate on her and remove the baby. During the surgical operation, she fell into comma and she and her baby died instantly.

4) A man of 48 years old was diagnosed with diabetics at a small government clinic. His case was transferred to a big government hospital. After two years or so battle with the disease, the doctor recommended that his left leg be amputated to prevent an infection from spreading to the other leg. The surgical operation was performed but it was the right leg that was instead amputated. When his brother visited that very day after the operation and found that his right leg had been amputated he complained to the doctor. That was it, no body took any action.

5) A woman age 39 accompanied her friend to a private clinic for a check-up. On reaching the clinic, the woman told her friend that she would stay outside while the friend went in to see the doctor. While she was patiently waiting for her friend, the doctor burst out of the door and beckoned her to come in. As soon as the woman went in and sat down, the doctor said,? I understand you have a fibrosis in your uterus and this has been bothering you for a long time now. Fibrosis can affect your reproduction ability, making it impossible for you to have any more children. I can operate on you today and remove the fibrosis once and for all. My operation is hundred percent guaranteed, and you will go home happier than you came here. The woman hesitantly agreed, but she died in the course of the operation.

6) Numerous cases of children age 2-5, who have suffered a permanent paralysis in their legs as a result of injections administered to them with the intent to treat them of malaria, measles, convulsive fevers, or bilharziasis, are commonplace in Ghana. Ghanaian medical doctors are too quick to use hypodermic syringes to administer injection to patients, even where it is absolutely not needed.

I quite remember during my elementary school days in Konongo, when I contracted bilharziasis as a result of swimming in a river near the entrance to the Konongo gold mines. The doctor prescribed 22 injections spread over a period of 44 days, meaning one injection every other day. Almost all my school mates who contracted the disease were prescribed the same number of injections. It was a common disease among kids in my school as well as those in the adjacent schools. Those days no health professional came to my school to educate us about bilharziasis; nor did the Ministry of Health erect any signboard by the river side warning children the danger against swimming in that river. Yet the government of that time was so vociferous about public health education, invariably taking an Evangelic and Messianic tone.

The point I want to make is that those prescription injections were absolutely unnecessary for the treatment of that disease, apart from the risk of getting injured from the hypodermic syringes. If you live in the Western world, tell me when was the last time your family doctor gave you an injection for headaches, stomach-aches, or fevers? I must admit that in Europe and North America people 50 years and over and children under five are vaccinated during the winter period to prevent them from catching the flu. Though some people in the medical community are opposed to flu vaccination, this is the only time hypodermic syringes are used on a massive scale. Comparatively, the situation in Ghana is different as the administration of injection has become an essential part of the health care culture. Indeed, most people who visited clinics, health centres, or hospitals where they were not given injections, may perceive that they were not properly treated. In other words, the administration of hypodermic injection is synonymous with having been attended to by a medical doctor. In some cases, some people request hypodermic injection where even the physician has not seen the need for it. However, I have heard some people arguing that the culture of hypodermic syringe injection is part of our colonial legacy-- the British colonial masters used it frequently as a therapeutic instrument. Other Ghanaians trace the problem to Ghana?s underdevelopment. This group believes that underdevelopment is not only economic, but also political, intellectual, cultural, social. Thus, according to that neo-Marxist reasoning, underdevelopment is a ubiquitous phenomenon that cuts across all facets of our society. Whatever its origin or source, after all these donkey years of independence, what are we doing about it? I am more interested in human commitment bounded up in action to bring about improved conditions of life. This does not imply that I am unmindful of colonial historical antecedent and how that continues to shape medical practices and the cognition of Ghana?s medical community and of our politicians. I believe that with tenacious commitment from individuals and groups Ghana can build a new, progressive healthcare culture.

From my perspective, three main reasons underlie the exponential growth in medical malpractices in Ghana. First, the average Ghanaian is deeply steeped in superstitious belief that death, illness, and other misfortunes in life are caused by satanic forces; hence, he or she hardly investigates or interrogates the causes of one?s death or illness. Second, the average Ghanaian believes that medical science and its practitioners are infallible. Simply expressed, the average Ghanaian does not believe that medical doctors could make any mistakes or cause the death of a person or carelessly damage the health of people. This factor has an implicit connection with the ideology of science, which frames scientific activities as objective, Messianic enterprise. Third, the power relationship between a medical doctor and a patient is unequal, always favouring the former. In Ghana, where the literacy rate is about 65 % and physicians- patient ratio is 1:22970 (1990), physicians have a lot of social, intellectual, and political clout. Hardly can a patient ask his or her doctor simple questions about the side-effects of a medical procedure or medications the doctor has prescribed. Nor could a patient or their legal representative challenge a doctor about the medical efficacy of a therapy the doctor wants to perform. This unequal power relationship allows physicians to do whatever they like without any punitive consequences.

Having said all that, where do we go from here as a burgeoning nation-state? The following measures may be appropriate to resolve the issues I have identified:

1) The government should pass a law, making it a criminal offence for any doctor found to have committed medical malpractices resulting in death or substantive physical injuries to a patient. For other categories of malpractices, monetary compensation would be sufficient. This would give victims of medical malpractices or their legal representatives the right to file complaint with the police.

2) The Ghana Dental and Medical Council (GDMC) should, as part of its discipline committee, establish a public complaint unit that would receive complaints against physicians. Complaints received must be speedily dealt with and the results communicated to the complainants. Any punitive punishment meted out to an offending physician should not only provide therapeutic satisfaction to the victim or their legal representatives, it should also serve as deterrence to future offenders. The GDMC must make its professional code of ethics accessible to the public through print or electronic media. That way people would be informed about what is expected of physicians.

3) The Ministry of Health must also establish a ?patient complaint unit? that will receive complaints from members of the public who have reasons to believe that a physician has committed a malpractice. This complaint unit would serve as a check on that of the professional body. That is, patients who are unsatisfied with the way the professional body has handled their cases could bring them to the Ministry. The main role of the Ministry is to mediate the resolution of the issues.

4) An open communicative relationship between physicians and patients must be part of the medical school curriculum and reinforced by the Ghana Medical &Dental Association?s professional education program for its members.

5) Public health education is sometimes peddled around as one of the solutions to health issues in Ghana. Any effective public health education program must include social aspects of health such as patient rights, doctor-patient relationship, and patient access to health information.

Concluding Remarks

First, the three channels of complaints are sufficient to ensure that victims of medical malpractices or their legal representatives would have justice. It is also a check against unnecessary bureaucratic delays or stone-walling. Second, medical malpractice should be distinguished from resultant side-effects of treatment or therapy. In an open communicative relationship between a physician and patient, the patient would be informed in advance of any side-effects or risks entailed in treatment or therapy. So side-effects or risks cannot be taken as malpractices.

Further, this article is likely to induce the indignation of some medical doctors in Ghana, who may feel that any law on medical malpractices would open a can of worms and it would make their work increasingly difficult. Some may even argue that such law would encourage more physicians to leave the country for greener pastures in other countries. However, that is a narrow argument. This is because whatever law the government passes against medical malpractices would not, in any realistic sense, come close to those in Western countries, where the Ghana medical doctor is likely to migrate.

Furthermore, some practicing medical doctors in Ghana are likely to refer to the GDMC?s code of ethics and The Declaration of Geneva (World Medical Association, 1948, 1968, 1983) as sufficient guides for practicing physicians in Ghana. The Geneva Declaration sets out strict ethical standards of practice for physicians, all over the world (general duties of physicians, duties of physicians to the sick, and duties of physicians to each other). For example, one of the general duties of a physician under the Declaration says this: ?A physician shall certify only that which he (or she) has personally verified.? Another one says that ?a physician shall not permit motives of profit to influence the free and independent exercise of professional judgement on behalf of all patients.? The problem with this international code of ethical practice is that it is a mere paper tiger, that can only bark at offenders without the force to bite. I want a code of ethics that barks, so to speak, and at the same time bits.

Regarding the GDMC?s code of ethics, they are enforced only when the major news media carried horrible stories of a doctor?s professional misconduct. For instance, the GDMC?s disciplinary committee meted out punishment to three doctors for professional misconduct after their misconduct had been published in some of the newspapers (Ghanaweb, January 10, 2003). In that news item, it was reported that the GDMC fined Dr. Takyi one million cedis for administering a concoction of six eggs, a bottle of F.A.C. and apkpeteshie. In addition, he was required as part of the disciplinary measures to have a letter of apology to the victim?s family published in the Ghanaian Times. Indeed, these disciplinary measures are just a slap on the face of the doctor?totally out of proportion to the severity of the offence. Perhaps the GDMC reasoned that because medical doctors in Ghana are becoming ?endangered species? doctors who have committed a serious professional offence like that should be allowed to practice again. But the behaviour of that doctor is not different from that of a quack doctor! Does Ghana need real doctors or quacks?

A law against medical malpractices would, in my opinion, help to prevent unnecessary deaths and health impairments of Ghanaians and also motivate physicians to exercise stricter care and judgement in practicing their craft. After all, the cardinal purpose of medicine is to save and improve lives rather than to kill or maim lives.