In Vitro versus In Vivo

What works in theory does not necessarily work in practice.  It is common knowledge that a drug that works in vitro (literally meaning “in glass”, which is in experiment settings) might not work in vivo (literally meaning “in life, or in human”).  Among other factors, the absorption, distribution, metabolism and elimination of the drug affect the concentration of it at its target site.  You might never reach the effective in vivo concentration in vivo without causing toxic effects to other organs.  However, another hard-to-believe but disturbingly true explanation for a drug not working in vivo is that, for one reason or another, the patient does not take the drug.

That also happened to my suggestion made to the Medical Council about not to criminalize doctors who had forgotten to renew their Annual Practicing Certificates.  In the Editorial of the September issue, I identified a situation where an apparently harmless mistake (forgotten to renew the Annual Practicing Certificate) might end in criminal conviction of the doctor and inability to practice for a long period of time.  This was because the doctor’s honest declaration that he had been practicing during that “window period” was taken to the strictest sense.  He was reported to the police for practicing while his name was not on the General Register.  I pointed out that in a similar case (Fong Ngai Chiu), the judge dismissed the criminal charge because he accepted the defense that the doctor believed for good and sufficient reason, although erroneously, that his name were on the General Register.  I pleaded the Medical Council Members to consider adopting the reasoning of such defense to exempt the absent-minded doctors from police investigations and criminal charges.

The suggestion was not going to work because Members did not take it.  There was legal advice stating that judgment from a district court had no binding effect on others.  Also, it was difficult for a doctor to say that he reasonably believed (erroneously) his name to be on the General Register because the Medical Council had sent out repeatedly registered letters to remind him.  That in itself was a reckless act.

Obviously this was not true.  It was hard to believe hundreds of doctors behaved recklessly every year.  The defense was not from the point of view of the Medical Council.  It should be from the point of view of the doctor.  A simple reason to explain how an absent-minded doctor could believe his name to be on the General Register was just that he had forgotten to update his address.  He was wrong to do so.  He had made a careless mistake.  But this should not be criminal.

Some members had different opinions.  Some insisted that such act was criminal and the Secretariat should report to the police whenever she encountered such declarations.  Some believed that the Medical Council was not in a position to give legal advice to doctors, especially those who had erred.  Some shared no sympathy with the absent-minded doctors and believed that harsh punishment was deserved.  Some found no problem with the current situation.

In conclusion, my suggestion did not work in vivo.  What I can do is to remind readers here to check whether you have renewed your Annual Practicing Certificate.  And I shall remind you later repeatedly.  However, I hope such act would not make the absent-minded doctors deemed more reckless.

Another sad outcome was from the Student Movement.  It was the situation where what worked in vivo did not work in vitro.  All along, scientists have been making various observations on things that happen in certain patterns, or something that work in certain ways.  The real challenges are how to elucidate the reasons behind such observations.  Why and how do things work?  Without knowing the true reasons behind, it would be difficult to reproduce the effects in artificial conditions with certainty.

For the Student Movement, it was planned to be the Occupy Central action which involved an estimated 1000 people to occupy Central for a day or so during a public holiday.  The aim was to arouse attention of Hong Kong citizens and international media on the issue of Chief Executive Election.  As you all know, it turned out to be near 10,000 people occupying different sites including major roads for more than 70 days.  No one knew exactly how these were sparked off.

In late November, while the Movement seemed to be caught in a dead end, student leaders tried to reproduce what happened in September 28.  Occupiers were asked to march against thousands of pre-informed police.  Sadly, what worked in vivo before did not work in such artificial conditions.  Many occupiers were injured, and so was the image of the Movement.

But I am not blaming any of the students.  Right from the start, no one would have expected them to achieve a political reform overnight.  Neither does Hong Kong need any revolution.  No matter how the Movement ends, their aim of sending a clear message to Hong Kong people has been achieved.  All of us will remember the yellow umbrella, the giant banner at Lion Rock, and various art works.

The Student Movement reminds me of Buddhist teachings.  The Buddha is not bringing you to the moon.  His teachings serve as a finger that points the way to the moon.  The right direction has been shown.  Everyone of us should work hard accordingly towards that direction.

(Source: HKMA News December 2014)

醫學會在哪裡？

假如說醫學會在「佔中」事件中表現令人滿意，相信未必會得到大部分人同意。可能不少會員心裡會問：「究竟醫學會在哪裡？」

這裡可以由兩個互相關連的情況分析：首先，醫學會在「普選」和「佔中」問題上比較沈默。尤其是「佔中」初期的一連串引起市民及各個界別關注的事件，醫學會並未發聲。今年三月，醫學會就政府政改咨詢向會者做了問卷調查，並就文件提供了調查結果和意見，開了記者招待會。之後，8 月 31 日，「人大」就普選方法提出「框架」，內容和醫學會會員意見有明顯落差；醫學會並未有跟進。9  月 28 日，87 枚催淚彈事件，市民及義工受影響；醫學會並未發聲。10 月 3 日，「子彈清場」威脅，醫學會並未見公開表示。終於，10 月終，醫學會大幅見報。亦有會長及會董蔡堅於不同媒體作訪問，內容卻是「佔中撕裂醫學界」、「醫學會政改民調激辯」、「佔領觸發醫學界師徒反目」等負面內部新聞。引發原因，卻是應否就「佔中」和普選等事件再作會員民調。噪音過後，就大家關注的普選與「佔中」事件意見，醫學會回復沈默。

第二點，是醫學會定位究竟在哪裡？究竟醫學會是否代表醫學界？醫學會又是否代表你？代表我？10 月 21 日，600 多位年輕醫生在報章刊登聲明，發表了他們對普選的意見。之後，醫學會收到會員要求，就該聲明用上了「醫學界」字眼澄清。醫學會當真計劃發表聲明，指 600 多醫生聲明「與醫學會無關」。但計劃被會董否決。10 月 28 日，另外 500 多位醫生於報章發表公開聲明，表達他們不同的立場和意見。之後，兩大醫學生出信回應。各種媒體亦就這兩則不同聲明有不少訪問和討論。11 月 4 日，首先發聲明的 600 多位醫生到醫學會遞交會員簽名信，要求就 831 方案等作會員民調。大家可能覺得，醫學會誰也不代表。

醫學會究竟在哪裡？遇上大事件，她何時會發聲？她的定位和立場在哪裡？是否有原則可跟從？又怎樣處理不同會員意見？

醫學會聲稱緊抱中立原則，特別是有關政治議題。背後理論是醫學會並非政治組織，而且會員有不同政見和立場。不過，在功能組別中，在「選委」中，在「提委」中，醫學界也是一個獨立而重要界別。醫學會又是否保持中立，不作參與？醫學會就政改咨詢表達了會員意見，任務是否就已完成？831 框架的明顯落差，醫學會又有否責任去了解會員意見，並且跟進表達？況且，世間上任何事情，不論政治與否，都很少會所有人意見一致。那麼醫學會的中立，如何執行？面對大是大非時，何時應放棄所謂中立的立場？

政治與否，很難定斷。連辦公室內也有所謂辦公室政治。面對暴力事件等明顯是人道問題，醫學會又如何一方面保持政治中立，一方面維護民康、保障會員？不表態、不發聲、不了解、不調查，又是否中立的表現？

就著這些和大家息息相關的問題，《會訊》決定做一個專題訪問。畢竟，醫學會的訊息，大家不應該只是從報章雜誌中得知。我走訪了會長史泰祖和蔡堅，因為他倆是今次「見報」主角。訪問當然會觸及事件前因後果。但爭拗雖然熱鬧，重點還是大家都屬於的醫學會。會員民調，暫時是不會進行的了。希望通過這次訪問，大家會更了解醫學會在政改和「佔中」的立場，和了解醫學會怎樣處理會員不同的立場。

最後，為了受訪者設想，和保持醫學會的中立，要附加一則重要聲明。為了視覺效果，我們一起到金鐘佔領區影相，時間是11 月 8 日下午 3 至 4 時。大家到場只是為了取景，並沒有參與集會式佔領行動。而且，當時下著不大不小的雨，所以大家都撐傘。而雨傘顏色純屬巧合，並不反映相中人對「佔中」的任何立場。

很累贅囉嗦啊！沒辦法啦！

 

(Source: HKMA News November 2014)

From the Editor

(Source: HKMA News October 2014)

Self-incrimination

This is very important.  A common minor mistake can turn into a criminal offence and prevent you from practicing for years.  Such mistakes are made every year by hundreds of doctors.  You might be one of them.

In 2013, a doctor was arrested in his clinic because of “practice of medicine without registration”.  He was then found guilty and fined $20000.  That was not the end of the story.  Since he had committed an offence punishable with imprisonment, he was caught by another section [s21(1)(a)] of the Medical Registration Ordinance (MRO) and he would need to go through investigations by the Preliminary Investigation Committee (PIC) of the Medical Council, and then might need to face an inquiry.  By the time, his name was still not on the General Register (GR).  He would need to wait for procedures such as a restoration hearing before he could start to practice again.

What had this poor colleague of us done?  Actually he had forgotten to renew his Annual Practicing Certificate.  After repeated reminders from the Medical Council, his name was removed from the GR.  He was caught not because he ignored the removal notice from the Medical Council and continued to practice after he knew of the removal.  He was caught because he incriminated himself when he filed the application form for restoration.  I have to tell you that there is a serious problem with the application form for restoration.  The applicant will end up either incriminating himself or making a false declaration.

To understand this typical “Catch-22” situation, I have to first get straight some facts:

1. A doctor has to renew his Annual Practicing Certificate before the end of each year.  If he fails to do so, after a grace period of 6 months, his name would be removed from the GR.
2. According to section 28 of the MRO, it is a criminal offence to call himself a doctor if his name is not on the GR.  He will be liable to a fine and imprisonment up to 3 years.  It is another offence if he practices medicine when his name is not on the GR.  He will be liable to a fine and imprisonment up to 7 years.  Moreover, he has to get rid of most of his medication stocks as he is no longer entitled to possess them.  Otherwise he would be liable to other fines and sentences of imprisonment according to the Pharmacy and Poisons Ordinance, the Antibiotics Ordinance and the Dangerous Drugs Ordinance.
3. When he is (finally) notified by the Medical Council that his name is removed from the GR, as a good and sensible citizen (as he is no longer a doctor), he will stop his practice and immediately file for restoration.  In the application form for restoration, he needs to make a declaration.  He needs to declare whether he has practiced medicine during the period when his named is removed from the GR.  It is this part of the form that makes him liable no matter what he declares. 
4. Obviously, if he is not aware of the fact that he has forgotten to renew his Annual Practicing Certificate, there ought to exist a period that he is still practicing before he is notified of his removal.  Our afore-mentioned colleague was honest enough to answer “Yes” to this question.  The result was that it amounted to self-incrimination and the police was notified.
5. What about answering “No” to that question?  In the notification of removal, the date of removal is given.  That means the doctor should be fully aware that he has been practicing between the date of removal and the date of being noticed.  He will be making a false declaration.  This, again, is a criminal offence.

Do readers feel akin to the ice-bucket challenge after reading the above facts?  Starting with a relatively minor mistake with no malice or fraudulent intent, a doctor can end up with criminal charges and be unable to practice for a long period.  This situation was brought to attention to the Medical Council.  However there had been to no avail.  The legal advice was that the applicant for restoration could choose not to answer that particular question.  Such advice was obviously nothing but absurd, if not an affront to common sense.

But don’t worry!  I have some important observations here for our members.  Every year, there are hundreds of doctors being removed from the GR in July due to failure to apply for the Annual Practicing Certificate.  They have to apply for restoration.  In all these years, I am not aware of any doctor being caught and found guilty of making false declaration.  You might draw an inference that the Medical Council is more tolerable to false declarations than self-incrimination.  I must point out firmly that I am not hinting such inference.  My advice is: try not to forget to renew your Annual Practicing Certificate.

As a member of the Medical Council, I think it is prudent to work out something more concrete to solve this problem than to provide facts for colleagues to draw inference.  I go through relevant sections of the MRO, procedures for restoration and cases on this matter.  There was a similar case in 2009 (Tong Ngai Chiu) and the judge dismissed the criminal charges.  The defense counsel brilliantly relied on the important defense developed from the case Fong Chin Yue.  I summarize as follows:

1. Section 28 of the MRO should not be interpreted in a way that there would be a “gap through which the innocent might fall to their harm”.  Criminalizing absent-minded-mistakes should not be the intention of the Ordinance.
2. Thus, there existed a defense to the charge.  “If the accused could prove on a balance of probabilities that he believed for good and sufficient reason, although erroneously, that the provisions of the Ordinance had been complied with”, he would not be guilty of the charge.
3. “A magistrate should approach such defence with fairness, common-sense, relevant consideration should be… whether the accused gained or stood to gain by offending the extent of any such gain, and how it compared with what he could earn by honest means.”

Following the decision from Tong Ngai Chiu, I suggest adding the following items to the restoration application forms:

1. Date of knowledge of being removed from the GR
2. Period the applicant has been practicing after his name was removed from the GR, if any
3. A declaration by the applicant that he believes for good and sufficient reason, although erroneously, that his name were on the GR during the period mentioned above

I believe (hopefully not erroneously) that such approach, with some refinement, can solve the Catch-22 situation for good.  I shall write to the Chairman of the Medical Council and introduce this approach for discussion.  In the meantime, please make sure you pay and apply for the Annual Practicing Certificate before the end of this year.  Since those absent-minded colleagues are removed from the GR in July each year, I don’t think anyone needs to draw any inference now.

(Source: HKMA News September 2014)

2 years' review; 2 years ahead

(Source: HKMA News August 2014)

The judges got it wrong?

The disciplinary power of the Medical Council of Hong Kong rests solely on its disciplinary procedures.  After due inquiry by an inquiry panel, a registered medical practitioner can be sanctioned ranging from being issued a warning letter, to the removal from the General Register.  Removal from the General Register is considered a very heavy penalty as the candidate ceases to have the right to practice medicine until and unless he is included in the General Register again.

How did members of the inquiry panel make such an important decision on whether a doctor is guilty of profession misconduct?  Members need to apply a “test”.  A test is a legal term.  We can see a test as a question resulting in either a “Yes” or a “No” answer.  If the answer to the question is “Yes”, the doctor concerned is guilty of professional misconduct.  In 1988, in a case heard in the Court of Appeal, the judge decided that the test to be: “whether the doctor's conduct has fallen short of the standard expected amongst doctors?”  Unfortunately, and with due respect, this decision was wrong and it paved the way to the dysfunction of the disciplinary procedures of the Medical Council.

In 1988, Dr. Koo Kwok Ho was found profession misconduct because his nurse was caught selling a dangerous drug to a patient.  He claimed that it was a single incident and the nurse had done it without his knowledge.  He lodged an appeal.  In the Court of Appeal, the judge referred to a case heard in the Privy Council in 1987: Doughty v General Dental Council.  In Doughty, the dentist was found guilty of “serious professional misconduct”.  Such term was introduced a few years back to replace the old charge of “infamous or disgraceful conduct”.  In his ruling, the Lord interpreted the statue and decided that the conduct did not need to be infamous or disgraceful to constitute professional misconduct.  He further explained that "what is now required is that the General Dental Council should establish conduct connected with his profession in which the dentist concerned has fallen short, by omission or commission, of the standards of conduct expected among dentists and that such falling short as is established should be serious."

It was perfectly appropriate for the judge in Koo Kwok Ho to rely on Doughty, particularly to follow that a single incident could constitute misconduct; omission could be misconduct; and that the conduct needed not be proved to be infamous or disgraceful to the profession.  However, the judge further distinguished from Doughty that in Hong Kong the charge was a bit different.  Thus, the judgment stated: “Save to observe that the Hong Kong ordinance does not require the element of seriousness, the relevant words being ‘misconduct in any professional respect’, we would respectfully adopt their Lordships' comments with respect to inquiries under Section 21 of Cap. 161.  It is unnecessary then to consider the application of emotive adjectives.  The test is simply whether the doctor's conduct has fallen short of the standard expected amongst doctors.”  This ratio decidendi was problematic.  It was understood that the disciplinary procedures of the General Dental Council in UK was similar to that of the Medical Council of Hong Kong.  The purpose was also similar in protecting the public by sanctioning undesirable behavior of doctors.  It was irrational to conclude that in Hong Kong the scope of the charge was totally different from that in UK and the fallen short of standard needed not be serious.  

Concerning statute interpretation, a recent decision from the High Court (Hong Kong Medical Association v Medical Council of Hong Kong HCAL 70/2012) gave a good summary on it: “It is a fundamental point in statutory interpretation to look at the relevant words or provisions having regard to their context and purpose.  This was made clear by sir Anthony Mason NPJ in his judgment in HKSAR v Lam Kwong Wai (2006) 9HKCFAR 574 at paragraph 63 where he explained that the modern approach to statutory interpretation insists that context and purpose be considered in the first instance, especially in the case of general words, and not merely at some later stage when ambiguity may be thought to arise.  This was reinforced in subsequent decisions of the Court of Final Appeal in HKSAR v Cheung Kwun Yin (2009) 12 HKCFAR at paragraphs 12 and 13 and Vallejos and Domingo v Commissioner of Registration [2013] 2 HKLRD 533 at paragraph 76 and 77.  Statutory interpretation therefore requires considering and understanding the relevant statutory wording or provisions in light of their context and statutory purpose.”

Taken out of context to decide that “professional misconduct in Hong Kong” was equivalent to “serious profession misconduct in UK that needed not be serious” was bound to result in absurdity.  Any fallen short of standard, no matter how trivial, could then be professional misconduct.  Unfortunately, the decision in Koo Kwok Ho was followed in Too Chun Fung v Medical Council of Hong Kong CACV 206/2000.  In Too Chun Fung, the appellant argued that there needed to be something more than just fallen short of standard to constitute professional misconduct.  The judge did not agree.  Similar decision was come to in Ip Wing Kin v Medical Council of Hong Kong CACV 627/2001.

Next month, I shall further write on the undesirable effects of the Koo Kwok Ho decision on the Medical Council, on doctors and on patients. 

(Source: HKMA News July 2014)

Disciplinary procedures

I have studied law, but of course I am not a lawyer.  I am a family doctor.  All my limited experience on legal proceedings comes from voluntary public services.  The one most closely related to my profession is the Medical Council.  I have been a General Member of the Medical Council for 9 years.  I even obtained a Master degree in Medical Laws to better equip myself.  I am also a member of the Barrister Disciplinary Tribunal and the Licensing Appeals Board of the Food and Health Bureau.

Although it is called an appeal board, the Licensing Appeals Board does not usually deal with complicated adjudication problems.  Cases go through the Board to buy time and as a standard procedure before lodging appeals to the Municipal Services Appeals Board.  Hearings are held in the Conference Room of the Central Government Offices with the Chairman and 4 Members.  Several cases are heard in a morning session.  It is more like counseling than judging.  I usually encounter restaurant owners who talked angrily, or cried sadly, but with no legitimate reason for the appeal.

Inquiries of the Barrister Disciplinary Tribunal are more formal.  It is quite an experience to sit at the judges’ bench of a court room in the High Court.  Obviously both parties are represented by counsels, who are instructed by representing solicitors.  Together with juniors, paralegals, interpreters and transcript writers, they quite make a scene.  Hearings are carried out after court hours, from 5:30pm till 8:30pm usually.  There are 3 members, 2 barristers and 1 lay member, acting as judges.  The Tribunal is very efficient.  I remember hearing a case which was quite complicated, involving ICAC and intermingled commercial issues.  It took only 7 hours, in 3 days, to reach a verdict.  In between, 5 witnesses were called and cross-examined.  Time management was strict.  Irrelevant issues were stopped and delayed tactics were frowned upon.

Inquires of the Medical Council are most demanding.  It needs 5 Members of the Council, or 3 Members and 2 Assessors, to form a quorum.  At least 1 of the 5 Panel Members should be a lay member.  Hearings are held at the conference room of the Medical Council at the Academy of Medicine Building at Wong Chuk Hang.  Hearings usually take 1 full day, from 9:30am till 6:30pm.  It is more and more common to have hearings which span more than 1 full day.  2 to 3 days seem to be the norm.  Recently, there was a case, which involved an obstetrician, that required nearly 11 full days for the whole process.  I did not take part in that inquiry.  It was also this case that led the public to criticize the Medical Council for delay in handling complaints.  Because of a strange comment that some Panel Members needed to leave on time so as “to celebrate Mother’s Day as scheduled”, the Inquiry Panel Members seemed to take the blame from the public more than the defendant doctor.  This is not fair.  In these 9 years, I have sat in around 50 inquires and acted as chairman in 2.  I remember once I was real exhausted after a 3-whole-day hearing.  I got a terrible headache.  Together with the oily and probably bad food for lunch from the canteen, I vomited twice and nearly ended up in A&E that night. 

Medical Council hearings are quite formal.  Strict procedures are set out in Part IV of the Medical Practitioner (Registration and Disciplinary Procedure) Regulation.  In short, the Secretary of the Medical Council, usually represented by the Legal Officer from the Department of Justice, reads out the notice of inquiry and the charges against the defendant doctor.  The Legal Officer then presents the case against the defendant, adducing evidence in support of it.  He may call expert witnesses and witnesses to testify.  Witnesses will testify under oath and are examined and cross-examined.  At the close of the case, the defendant, usually legally represented, can make a no case submission in the point of law.  The Inquiry Panel Members have to make a decision on it.  If it is rejected, the defendant is required to state his case.  At the conclusion of the case for the defendant, both parties may make closing submissions.  The Legal Advisor will then tender legal advices on the case.  The Inquiry Panel will then deliberate and make a decision on whether the defendant is guilty of the offence charged.  If the defendant doctor is found guilty, he will be invited to address the Panel by way of mitigation.  He may adduce evidence as to the charge or personal background of the defendant.  The Panel then decides on sentencing.

The procedures are quit complicated.  I have heard repeatedly from Members that justice takes time.  I do not fully agree on that.  Lengthy procedures are unfair to both parties, the complainant and the defendant doctor alike.  Lengthy inquires will also slow down the complaint handling procedure as a whole and is thus unjust to the long waiting queue of complainants.  This is one of the focuses of criticism of the obstetrician case.  There are some areas for improvement.

Written submissions should be encouraged and better prepared.  I seldom receive agreed facts or even the defense’s bundle well before an inquiry.  Lengthy reading out words by words from such documents can be dispended of.

“He who decides must hear.” is the principle for nature justice.  However, it does not mean that the defense can drag on irrelevant issues or elaborate indefinitely on well taken points.  Case management is deemed the norm rather than jeopardizing the rights of the defendant.

Deliberation and decision on whether the defendant doctor is guilty of the charges take time.  And I agree that it should take as much time as it is feasible.  However, experience tells us that it seldom takes hours for decision making.  There is also a mechanism of majority votes for reaching a decision when there is no chance of reaching a consensus.  It is the writing of the judgment by the Legal Advisor that takes time.  The previous Legal Advisor usually took several hours to write several pages of judgment.  I am not going to comment on the practice of another professional.  But the Inquiry Panel can always announce the decision of guilty or not while the full judgment be handed down later.  Mitigation factors can then be heard from the defendant.  The Panel can deliberate and decide on sentencing, which is again to be announced later.

The above are some of my experience and thoughts on disciplinary procedures.  In response to the call for reform of the Medical Council, I would then present some other thoughts on this topic in the following issues of the News. 

(Source: HKMA News June 2014)

With Great Power Comes Great Responsibility

This month, I got confused when I saw commercials about the movie on Spider-man 2.  As far as I could remember, I should have watched Spider-Man 1 and 2 years ago.  I still remembered the main theme, apart from fighting against bad guys and monsters, was that Spider-Man was human.  He had to face all mundane troubles and sufferings of life.  Actually our hero, Peter Parker, was even disadvantaged by his super power.  He had to hurry here and there to save countless lives.  His super power was nevertheless not all-mighty.  He would get hurt.  He had to practice his skills.  He made mistakes.  Worst of all, he still had to find a job so as to pay his bills. 

I did a bit internet searching and found out that actually the now-showing movie was called The Amazing Spider-Man 2: The Rise of Electro.  It served as a sequel to the 2012 movie The Amazing Spider-Man.  What I remembered were the trilogy: Spider-Man in 2002, Spider-Man 2 in 2004, and Spider-Man 3 in 2007.  For the trilogy, Toby Maguire was Peter Parker and Spider-Man.  Kirsten Dunst acted as Peter’s girl friend Mary Jane Watson.  In The Amazing Spider-Man 1 and 2, Andrew Garfield acted as Peter Parker and Spider-Man.  Emma Stone acted as Peter’s girl-friend, whom was a different one from the trilogy, Gwen Stacy. 

I did not remember watching The Amazing Spider-Man.  I am not too fond of these kinds of comic movies.  The plot is usually weak.  The focus is mainly on special effects, especially with 3D technology.  However, I did like Spider-Man and Spider-Man 2.  The message was clear: Life is multi-dimensional.  Being talented in one area does not mean that you will be exempted from all other sufferings.  While Peter was exhausted and neglecting his beloved ones (including himself), he questioned his heroic acts of saving others.  Then came the famous quote from his uncle Ben Parker: “With great power comes great responsibility.”  Peter got instant enlightened on hearing this and continued the struggle with his great power. 

Obviously I did not attain enlightenment as easy.  Was it true that with great power there came great responsibility?  Why didn’t the owner of great power enjoy himself?  Or could he not take advantage of his gifted power and bully others?  I recalled reading a book written by Michael J. Sandel named Justice: What’s the Right Thing to Do?  The writer explored three approaches to justice.  One says justice means maximizing utility or welfare – the greatest happiness for the greatest number.  The second says justice means respecting freedom of choice – either the actual choices people make in a free market (the libertarian view) or the hypothetical choices people would make in an original position of equality (the liberal egalitarian view).  The third way says justice involves cultivating virtue and reasoning about the common good.  The writer favored the third mentioned way of justice.  He believed that justice was not only the right way to distribute things.  It was also about the right way to value things. 

The arguments were complicated, and each not without its shortcomings.  However, it seemed that it was common ground that resources of the society needed to be distributed.  It was only the ways of distribution that were not in agreement.  John Rawls (representing the liberal egalitarian view) in his book, A Theory of Justice, gave a very good explanation on why distribution of resources served the purpose of justice.  He invented the Difference Principle, which stated that “only those social and economic inequalities are permitted that work to the benefit of the least adapted members of the society.”  He explained that “The difference principle represents, in effect, an agreement to regard the distribution of natural talents as a common asset and to share in the benefits of this distribution whatever it turns out to be.  Those who have been favored by nature, whoever they are, may gain from their good fortune only on terms that improve the situation of those who have lost out.  The naturally advantaged are not to gain merely because they are more gifted, but only to cover the costs of training and education and for using their endowments in ways that help the less fortunate as well.  No one deserves his greater natural capacity nor merits a more favorable starting place in society.  But it does not follow that one should eliminate these distinctions.  There is another way to deal with them.  The basic structure of society can be arranged so that these contingencies work for the good of the least fortunate.”  Those gifted by the lottery of nature were only in an advantage because the society happened to value their talents.  Rawls maintained that even efforts in later life could be the product of favorable upbringing.  “Even the willingness to make an effort, to try, and so to be deserving in the ordinary sense is itself dependent upon happy family and social circumstances.”  “It seems clearly that the effort a person is willing to make is influenced by his natural abilities and skills and the alternatives open to him.”

So Uncle Ben did make sense.  With great power comes great responsibility.  I did see followers of Uncle Ben around.  Some of them tried their best using every means to increase their power.  Before accomplishing great power in their own subjective sense, they bore no responsibility at all.  Some of those with great power exercised their great responsibility towards a few selected by their own good selves.  Some others took the great responsibility to impose their value judgment on us, the less gifted.  

(Source: HKMA News May 2014)

Do we need more Council Members?

 

By the time you read this Editorial, you should have received a notice for Extraordinary General Meeting (EGM) of the HKMA.  I am not going to copy and paste the notice here.  Basically, the EGM is supposed to pass a resolution of increasing the number of Council Members of the HKMA Council by 3.  That would increase the total number of Council Members from 18 to 21.  Together with the President, the 2 Vice-presidents, the Hon. Treasurer, the Hon. Secretary, the Immediate Past President and the invited Legco Member, the total number of members in the Council will become 28.  The 3 new Council Members will be added altogether this year via election, though their terms will be for three years, two years and one year respectively according to the votes they get.  That means we have to elect 9 Council Members this year.  Accordingly, the quorum of Council Meetings will be increased from 6 to 8 members.

From past records, the HKMA seldom, or if it did happen before, had problem with passing resolutions in General Meetings.  The obvious reason is that our members are satisfied with the Council and the running of the Association.  Therefore they do not bother to turn up and raise questions for the Office Bearers.  This has usually been the case in Annual General Meetings (AGMs).  For this issue of increasing the number of Council Members, it was not raised in the AGM last year, and it is not going to wait for the coming AGM in July this year.  An EGM has been considered necessary.  For this EGM, it falls on a busy Monday night, lodged between a Sunday and a Public Holiday.  Therefore the only problem foreseen is not on challenges and questions, but on meeting the quorum of 15 members.  Luckily, this EGM also falls nicely on a Council Meeting; therefore the quorum should not be a problem.

The reason given for increasing the number of Council Members by 3 is: “The number of members of the HKMA has increased for more than one-third from around 7300 in 2007 to more than 9900 in 2014.  There is an increased number of activities in the Association so much so that it will be more beneficial to the Association to increase the number of Council Members.”  The reason is pretty obvious, though it is up to members’ own imagination on how many activities are increased, how they are related to the present number of Council members and to the increased number of Council Members, and how it is going to benefit the Association.

I remember reading a business novel which is said to illustrate state-of-the-art economic theories.  It was written by Eliyahu M. Goldratt and Jeff Cox and published in 2004.  The name of the book is: The Goal: A Process of Ongoing Improvement.  The story is about how a factory manager achieves his goal of improving output of his plants through the help of piecemeal advices from a college professor who skillfully puts interesting economic theories into actual practice.  Here, the goal of Council is to better handle the increased activities of the Association.  The means chosen is by increasing 3 Council Members.  The logical question to ask is: Can the means lead to achievement of the goal?  We also need to consider whether there would be any unwanted effects.  Are we talking about manpower alone, or about efficiency?  There is a very basic economics theory called the Law of Diminishing Returns.  It states that in all productive processes, adding more of one factor of production, while holding all others constant, will at some point yield lower per-unit returns, or even negative returns.  Do not forget that an important, if not the more important, role of the Council is decision making in policies.  A council tends to become dysfunction when it grows in size.  For a particular matter which is not overtly complicated or important, if each of the 28 members gives his view for 5 minutes, the discussion will end up for more than 2 hours. 

It is efficiency that matters.  I came across another interesting economics principle on efficiency in my study days.  It is called Pareto Principle.  It states that for many events, roughly 80% of the effects come from 20% of the causes.  It is an observation proved by complicated mathematical calculations.  The reasons behind such natural order are again complicated and multi-factorial.  Put it simple, you can say that 80% of your clinic income comes from 20% of your load of patients.  Or, 80% of the complaints you receive come from another 20% of your patients.  The Italian economist Pareto developed his principle in the 1900s by observing that 20% of the pea pods in his garden contained 80% of the peas.  We can safely expect that 80% of the activities of the HKMA will still be handled by 20% of the Council Members no matter the total number is 25 or 28.  Thus, adding 3 more members without looking into other aspects of how these activities are handled (or, more fundamentally, whether such activities are needed) might not benefit the Association too much.

(Source: HKMA News April 2014)

From the Editor

(Source: HKMA News March 2014)

Permanence of Objects and Impermanence

 

During Chinese New Year holidays, I stayed in Hong Kong and did not have any special arrangement.  I tried to finish the few books that I began but failed to finish last year.  It turned out that I did not show much improvement in the New Year.  It took much endurance to finish a boring book, especially the one that you were not interested in finding out what the story was going to happen.  My mind drifted, from what had happened in the past year to what is going to happen in the coming year.  That was too wide a scope even for mind-drifting.  So I tried to narrow the scope to a month’s time.  That was: what to write for the Editorial of the News in February.  Even that was not easy.  It did not mean that nothing worth to be discussed.  On the contrary, there were too many happenings from the Council of HKMA, to the Medical Council, to the medical profession, and, to Hong Kong.  However, most of them were depressing and might not be a good topic to start a new year.  It is time to talk about weather.

The beauty of Chinese New Year is that you would see relatives whom you might seldom see otherwise.  I played with two 7-month-old babies during the holidays.  In return to my lai-see, they gave me their intestinal viruses.  I got gastro-intestinal upset for two days, though I still managed to attend barbecue gathering and hot-pot dinner.  Well, this part is irrelevant.

One of the small tricks I liked to show the non-medical relatives was the demonstration of sense of object permanence.  Babies like to grasp objects, swing them, and then hit against the table, and then against their heads.  Common objects include ceramic spoons, mobile phones, and every valuable and fragile thing they can get hold of.  My way to confiscate the object so as to protect the baby was to cover his eyes with my one hand, and then quickly seized it from him.  Paediatrics teachings from the old days told me that at the age before 8 months, most babies did not have the idea of permanence of objects.  That meant when the object disappeared from his visual field, it was gone, and was never there.  There was no cause-and-effect relationship for the past, the present and the future of an object.  After some time, when the circuit in the brain developed, and from learning through daily experience, the baby grasped the “reality” that objects would remain there for a considerable period of time.  This is called permanence of objects.

Another regular function of my Chinese New Year holidays is to visit Po Lam Monastery in Lantau Island with my classmates from Buddhist Studies.  This year, after I played my usual trick of object permanence with the two babies, I went to Po Lam the following day.  While having vegetarian lunch, I recalled the teaching of the Buddha.  The 3 marks of existence are: suffering, non-self, and impermanence.  Not only that all conditioned things are impermanent, their mere existence are doubted and negated.  It is through the delusion of the existence of a “self” that we grasp on all these in-fact-impermanent things.  As an unavoidable consequence, we would suffer loss, because things will perish, including ourselves.  Thus, we suffer.  The Buddha has claimed that his teaching covers only sufferings and the cessation of sufferings.  He has come to the real understanding of existence and he points out the way to the cessation of the inevitable sufferings.  However, it is not easy to achieve.  It might take the whole life time to practice diligently, or some might rarely get sudden enlightenment on the special teaching by a Zen master.   

But wait, how about the 7-month-old babies?  At that point of time, they know the presence of an object.  However, they do not have the sense that the object is permanent, at least for the period of time concerned.  It is only through observation day in and day out that they get the impression of persistence and permanence.  Of course this sense is essential for our daily living.  Otherwise, we cannot even identify our parents and look after our own belongings.  Separation anxiety in fact might be one kind of pathological conditions where the sense of permanence fails to develop and to mature.

The above was the irony that I came to after the holidays.  Life is like this.  We learn, we gather, we collect, and we treasure many things and phenomena so as to adapt ourselves to living.  We treat these as “realities”.  However, these might be the source of suffering especially when we face losses.  Even with the right view and practice, it is difficult to remove the hard-learnt and deep-seated experiences.

(Source: HKMA News February 2014)