Medical bribery and the ethics of trust: the Romanian case.

Journal of Medicine and Philosophy, 40: 26–43, 2015 doi:10.1093/jmp/jhu049 Advance Access publication December 10, 2014

Medical Bribery and the Ethics of Trust: The Romanian Case Teodora Manea* *Address correspondence to: Teodora Manea, PhD, 19 Saxon Road, Exeter, EX1 2TD, UK. E-mail: [email protected]

Medical bribery seems to be a global problem from Eastern Europe and the Balkans to China, a diffuse phenomenon, starting with morally acceptable gratitude and ending with institutional bribery. I focus my attention on Romania and analyze similar cases in Eastern European and postcommunist countries. Medical bribery can be regarded as a particular form of human transaction, a kind of primitive contract that occurs when people do not trust institutions or other forms of social contract that are meant to guarantee their rights and protect their interests. Concluding with strategies to fight medical bribery, I will underline better public policies for financing health and social care, and an ethic of trust that may help to restore trustworthiness of institutions and to rebuild interpersonal trust. This should be complemented by an educational program dedicated to understanding the negative consequences and mechanisms of corruption and the importance of ethical behavior. Keywords: gratitude, medical bribery, patient–physician relationship, postcommunism, trust I. Background and causes of medical bribery Medical corruption is a phenomenon with different shades and degrees of immorality. Someone may just show their gratitude by giving the doctor a card, a bouquet of flowers, a box of chocolates, or an expensive wine. Gratitude is part of our socially accepted norms and giving expression to it is generally morally acceptable. The gift only becomes bribery and as such morally questionable when it is given (by the patient) or requested (by the doctor) as a condition for the provision of health care, access to medical © The Author 2014. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: [email protected]

Downloaded from http://jmp.oxfordjournals.org/ at Nanyang Technological University on June 11, 2015

University of Exeter, Exeter, United Kingdom

Medical Bribery and the Ethics of Trust

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equipment, tests, procedures, or a certain quality of care. Another kind of bribery occurs between pharmaceutical companies and doctors, when they try to manipulate the doctors to prescribe a certain kind of medicine in exchange for pocket gifts, sponsorship of conferences, or conference participation. I call this institutional bribery because it regards the interaction between pharmaceutical companies, which are guided by their financial interests, and health care systems. This kind of bribery seems to be more present in industrialized countries (Elliott, 2010). Why is bribery morally problematic in the first place? The illegality of medical corruption is not a sufficient proof of its immorality. If it is morally acceptable to tip a waiter, why should it be regarded as unethical to give money to a doctor, especially when it is known that they have quite low salaries? The difference is that in the case of a waiter the tip is optional, just as it is optional to opt for or against this type of entertainment or social activity, whereas going to see a doctor is in most cases a serious and necessary activity. What is at stake is people’s health and sometimes life. And not only people’s own life and health but also that of those close to them and their family, which is due to the way we deal with and understand our responsibilities. In most cases this is not a matter of choice, which is why health care should not be conditional on personal favors. A health care system has the duty to protect people’s basic rights, which includes the right to health. Doctors are the guardians of this right and therefore we should expect that they will safeguard our health with objectivity and professionalism, providing all citizens entitled to health care with the quality and quantity of services that their situation requires. If bribery enters the care system, the objectivity of the doctors may be affected by it, as well as the fair distribution of health care resources. People with poor economic resources will be discouraged from seeking care or discriminated against in receiving sufficient quality of care. It is of course thinkable (though extremely unlikely) that a doctor takes bribes only from people who can afford it and treats those who cannot afford it with the same requested professionalism; it would seem that such a doctor would do nothing morally wrong. However, people would not be able to trust such a doctor. Medicine is not an exact science, which makes it difficult to assess objectively the received quality of care. Subjective, emotional, cultural, and personal aspects inform the subtle construction of trust between patient and doctor, which would be severely damaged if the patient knows that his doctor accepts gifts from the well-to-do. Am I really healthy? Is my medication the best available one? Am I on the right place of the waiting list? Would she/he put the best of her/his knowledge and skills to save my child? None of these questions can be positively answered without trusting the doctor. Regarding the processes involved in health care, corruption can occur with respect to the following: (1) provision of services by medical personnel; (2) human resources management; (3) drug selection and use; (4)

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procurement of drugs and medical equipment; (5) distribution and storage of drugs; (6) regulatory systems; and (7) budgeting and pricing (Nordberg and Vian, 2008). Health care systems around the world are vulnerable to corruption (Dyer, 2006), and corruption can affect every level of health care practice, from central government to patients themselves. International agencies and organizations like Transparency International, U4, WHO, and World Bank try to map the global corruption and its cost to public health, and to show the vast scale that exists in both rich and poor countries. The restored democratic regimes in Eastern Europe have to deal with an extra difficulty created by a higher level of corruption in the public systems, which affects health care, education, and the functioning of state institutions generally (Transparency International, 2013). This may be explained by the common communist past, but the problem of corruption affects the Balkans as well. Turkey and Greece, although having no communist past, deal with the same problem. Romania is situated at the geographic confluence of Eastern Europe and the Balkans, and the country is pervaded by a culture of corruption. This makes the Romanian case particularly interesting for my analysis. The European Commission’s (EC) reports from 2009 and 2012 criticized Romania for not making enough judicial changes and efforts to fight corruption. Since 2007 over €12 m from the EU budget have been invested to support the fight against corruption and judicial reform in Romania (EC, 2012). The health care system especially seems to be affected by everyday bribery. The situation is quite paradoxical, because the population complains about this kind of small bribery, but at the same time habitually practices it. This practice, so present in the Romanian society, seems to be unknown in Western countries. Is this phenomenon specific to Romania? Are Romanian physicians a particularly corruptible category of people? From my work1 with numerous Romanian physicians, I know that this is not the case. When working in other Western countries, Romanian doctors behave just as professionally as their colleagues, following the same high ethical standards. If the causes of corruption are not to be found on the individual level, the problem must be due to the social-economic and cultural environment. The Romanian health care system has undergone a series of more or less inspired reforms since 1990. The most important changes that were introduced are: the implementation of a health care insurance system and the decentralization of health care. These reforms effected a transition from a communist Semascko health system model (where everything was financed from the national budget) to a health insurance system with compulsory health insurance for employees (Bara, Van den Heuvel, and Maarse, 2002). Although the healthcare reform registered some positive effects, the quality of health services is still behind that of other European countries. For example, in 2009 the life expectancy was only 73 years, compared to more than 80 in other EU countries (World Health Organization, 2011). Poverty of the population,


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II. Communist Past: Corruption and Gratitude Romania shares its communist past with other Eastern European countries that were part of the Soviet Bloc. The communist past seems to be a red thread connecting countries in which medical corruption is widespread, for instance in China. Fan argues that misguided governmental policies have distorted the behavior of physicians: The distorting policies include (1) setting very low salaries for physicians, (2) providing bonuses to physicians and profits to hospitals from the excessive prescription of drugs and the use of more expensive drugs and unnecessary expensive diagnostic procedures, and (3) prohibiting payments by patients to physicians for higher quality care. (Fan, 2007, 11)

So, the grounds of medical corruption seem to be paved by inefficient or unwise governmental health policies. Just like their Chinese colleagues, the Romanian physicians have very low salaries, and there is no official system in place that would reward good performance. But for primary health care, Romanian family doctors are paid a mix of age-weighted capitation (85% for


especially in rural areas, as well as unemployment, renders the health insurance system inefficient. The Romanian health care system is under-financed, and this fact shows a kind of political indifference regarding general social protection and welfare of citizens. In 2011, the health expenditure was only 3.4% of GDP (similar only to Cyprus within the EU), compared to 8.0% in the United Kingdom, 8.3% in France, or 8.5% in the Netherlands (Freysson and Wahrig, 2013). It may seem quite obvious that generally the underfinanced health system and low salaries for medical personnel are the main causes of corruption. In addition, this situation generates another complementary phenomenon, adding more problems for the quality and functionality of healthcare: medical migration. One study from 2007 on Romanian medical migration showed that 54% of the questioned physicians would like to work abroad; 89% of these would like to work in an EU country. The main reasons for working abroad were low wages in the Romanian health system (55%) and poor working conditions (40%). The physicians complained about the level of financing (48%) and the organization (40%) of the health system. The main two reasons for complaining about daily activities were the lack of resources (especially modern medical equipment) and limited career opportunities (Vladescu et al., 2008). Together, all the causes mentioned above make Romanian health care precarious and both medical personnel and patients unhappy. For Romanian politicians, this particular problem was never a priority. One reason for this is that the political practice in Romania is still very much rooted in the country’s communist past.

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that this practice, unheard of in western medicine, is apparently typical to all countries of the former Soviet Bloc. This is a peculiar approach which can in no way be justified by appealing to the dignity of the medical vocation and profession, irrespective of whether its root cause lies in the conduct of the nouveau-riche, unaware of how to behave and desiring to emphasize their social standing, or in compassion caused by consideration of doctors’ difficult material situation, or else whether it is simply prudence dictated by past experience. (Szawarski, 2005, 28)

The root causes presented by Szawarski—the conduct of the nouveau-riche, prudence, or social compassion—are possible explanations, but they do not go deep enough. Why do the nouveau-riches behave this way? If there is something like social compassion, then the younger physicians should receive more money than the well renowned doctors in university clinics, but this is not the case. A higher professional status involves higher patient “contributions,” at least in Romania and China (Fan, 2007). Although the low wages of doctors are invoked in some reports (Lewis, 2000, 1–34) as a reason for patients to top them up with some extra money, this may be a form of moral self-justification, or a social construction created to avoid the responsibility for an immoral action. The doctors have indeed low wages and this is true for other public employees like teachers as well. But it is hard to imagine parents sending their children to school with some extra money for the poor teachers. Bribery is not charity for public servants. Szawarski mentions a study about informal payments in the Polish health care system conducted by Poland’s Batory Foundation in 2001, which revealed that among the 1,000 people questioned 356, or 36%, declared that they did indeed offer doctors and other employees of the healthcare system money or other objects (Szawarski, 2005, 29). The extent of medical bribery in Romania seems to exceed that in Poland. Some newspaper articles talked about a culture of corruption that is so embedded in Romania that surgeons demand bribes to save infants’ lives (Bilefsky, 2009; Mutler and Ghirda, 2012). Even the Romanian health secretary Ladislau Ritli admitted the extent of corruption: “to be honest, it’s so deeply rooted in our system that it’s really difficult to eliminate.” Patients in Romania discuss the “stock market” rate for bribes:


2005–2007) and fees for service (15%). These fees are for services such as immunization, monitoring some chronic diseases, and mother and child surveillance (Vladescu et al., 2008, 71). In private hospitals the payment rules are clear and seem to work well, because the charges are not unofficially supplemented to enhance the quality of care.2 Other postcommunist countries encounter similar problems (Szawarski, 2005). Investigating the boundaries between gratitude and medical bribery in Poland, Szawarski examined a waiter model of gratitude involving doctors, where the medical profession seems to be reduced to a simple service activity. He stressed


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Surgeons can get hundreds of euros and upward for an operation, while anesthetists get roughly a third of that, depending upon what a patient can afford. Nurses receive a few euros from patients each time they administer medications or put in drips. Getting a certificate stamped to have an operation abroad can easily cost hundreds, if not thousands of euros if you ask the wrong doctor. While the Romanian state appears unwilling to do anything, it often ends up footing the bill. (Mutler and Ghirda, 2012)

While some of the atentie are simply given according to tradition or to express appreciation, it is clear that often the atentie have the characteristics of bribes. Hospital stays, with the most frequent and largest payments, are equally likely to involve money as gifts, whereas gifts are the norm for the other forms of medical facility. When asked the reasons for unofficial payments for health care, the most important reason, cited by 45% of respondents, is to receive proper or speedy care; 21% said it is done out of tradition; and only 11% reported that unofficial payments are made to express gratitude. (World Bank, 2001)

III. Communist Past: Social and Interpersonal Distrust Medical bribery seems to be a particular form of a human transaction, a kind of primitive contract that occurs when people do not trust the institutions or other forms of social contract that are meant to guarantee their rights or protect their interests. I understand institution in a wide sense to include political, economic, social, and cultural institutions, in short everything that is based on a system of constitutive rules permitting the creation of institutional facts (Searle, 2010, 10). For societies that made the social experiment of communism (and maybe this idea can be extended to other forms of dictatorship), trust in legal, political, and media institutions is very frail indeed. The systems of thought or social practices involved in bribery are often governed by intricate rules that operate beneath the consciousness of individual subjects as part of the background power. This explains why some people just give something to a doctor without being asked, but just because “this is the way it works.” This behavior is dictated and sustained by a system of conceptual beliefs that determines the patterns of thought and action in a given domain and period of time. The system of conceptual beliefs shows why it is so hard to change or abolish that kind of social practice. Social, cultural, economic, and political elements are all involved in the practice of bribery, and we are going to see how from these different perspectives the final image of medical bribery is composed.


A World Bank Report in 2001 mentioned that Atentie (“attention,” meaning gift in our context, and being normally a white envelope filled with money) was paid by 2 out of 3 respondents that had recent visits to the hospital, and between 32% and 57% who had visited other types of medical facilities.

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Unlike other communist countries in the region, Ceausescu’s regime steered the Socialist Republic of Romania on a course of ever-increasing hard-line politics and daily hardship. Duplicity as communicative style and complicity as communicative act marked the politic servitude of the population and the disintegration of any notion of civil society as well as of the self. (Kligman, 1998, 241)

To keep control over the population, the displaced power of constitutive rules was replaced with an oppressive one. A secret police was instated, which infiltrated society. The power of fear replaced the power of legitimacy. Public denunciations were used for everything, from denunciation of dissidents to personal vendetta. Under the veil of anonymity you could destroy anyone, with just a denunciation, without any proof. The state encouraged this kind of denunciation, because they raised the fear and the sentiment of a panoptical power (Foucault, 1975, 208–24). The Romanian Secret Service, Securitate, employed around 15,000 officers and between 400,000 and 700,000 informers for a population of about 23 million (Stan, 2009, 6). The trust in society or its institutions was damaged, maybe for a longer time than expected, and it is hard to believe that more than 20 years after the revolution the social trust has already been reinstated; the political problems of the summer of 2012 provide sufficient evidence that it is still lacking (Thorpe, 2012). Bribery is one of the consequences and at the same time an indicator of the level of mistrust. In communist Romania, health care was free for everyone: centralized, controlled, and making the ideological game. The illegality of abortion, a consequence of Ceausescu’s demographic policy, encouraged the development of a black market for abortion (Kligman, 1998, 87–115). The practice of illegal abortion was not only dangerous for the women because of improper medical conditions, but it was a very hazardous practice for physicians as well. The danger of being discovered by the secret police was that one could end up spending years in prison and losing one’s medical license. In this case, because of the high risk present for both parts, the limits of gratitude


Which mechanism of human psychology leading to present corruption was influenced by the experience of living in communism? To answer that, it is important to distinguish between the communist ideology and the communist practice. The ideology was certainly damaging as well (Kligman, 1998), but the communist practice that poisoned the society is more likely to be the cause of corruption. The eradication of the old institutions and the artificial replacement with new ones, as well as the massive population movements from rural into urban areas, jolted the socio-political stability of most of the Eastern European countries after World War II. Everything was changed overnight; the system of constitutive rules was denied and put on an artificial basis. In some countries like Romania, the secret police and the practice of public denunciations all but destroyed the general trust in other individuals as well. Kligman confirms this Romanian particularity:


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IV. The dynamic of bribery: gratitude or corruption? In order to make more visible the line between gratitude and corruption, I will focus on two categories: time and initiator. In relation to time, bribery is mainly an ante factum action, preceding the act of health care, in contrast to forms of expressing gratitude, which are usually post factum. The expression of gratitude can encompass quite a wide range, according to the specific culture and economic power of patients: from cards, flowers, or chocolates to sums of money or expensive gifts. The initiator of bribery may vary, and with it the nature of bribery as well. There are three possible situations to be considered: (1) when the person who initiates the bribe is the patient or her/his family; (2) when the one clearly expecting or conditioning the action of care is a physician or a nurse; and (3) when the patient gives and the physicians accepts because “this is the way it works”—a kind of un-reflected traditional behavioral pattern. The patient’s intention is to influence, through the process of bribery, two main things: (a) a medical decision, and (b) the


and bribery were very difficult to draw. Women needed the illegal interventions of physicians and therefore had a good reason for using bribery and creating their own private contract and insurance policy. But because the physicians were putting their own lives at risk, compensations for the illegal service or gestures of gratitude for resolving a difficult situation were present as well. The goods exchanged were often of a symbolic nature, as “imported” products (Kent or Marlboro cigarettes, whisky, coffee, chocolate, etc.). There were a few similar practices in the Eastern bloc, for example, giving Kent cigarettes to doctors. Kent cigarettes were a sign of appreciation and quality. To give a packet of Kent to a doctor was a kind of symbolic recognition of his or her status. What kind of ingredients were in it: symbolic potlatch, subversiveness, reassurance. It was not the same thing whether one was offered the money value equivalent or “Snagov,” the best Romanian cigarettes. Somehow Kent, the white, elegant cigarette, was associated with the medical profession (Wong, 2012). Ness, whisky, Marlboro, caviar, sturgeon-fish were the special bribery things, something rare, praised, and precious. With the exception of the fish, all other goods were “imported” and available only on the black market, or in “shops” (duty free shops or foreign currency shops around harbors and in airports). There were good and very good Romanian products around and sometimes it was possible to find some Eastern bloc good quality products on the market as well, but they did not have enough symbolic value to be traded for health. The Western provenance was a tacitly agreed-upon sign of quality and maybe a subtle manifesto of freedom. The background power was different in communist times because medical bribery resembled gratitude and it was infused with symbolic value.

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very much depends on social conventions and cultural patterns of the given society. In our cultural tradition what constitutes a typical “expression of gratitude” in the urban society is still a bouquet of flowers or a bottle of good alcohol, while in rural areas, according to the accounts of retired physicians, it was, until very recently, several eggs or a wad of butter. (Szawarski, 2005, 28)

The gravity of a medical situation plays a key role in the dynamic of bribery. A life-threatening situation will force the patient to ensure in advance the success of a medical intervention. Someone may take a chance for a routine treatment, but for cases of cancer treatment, the best specialist will be accessed and adequately provided with the “envelope” (filled with money,


quality of the medical act. The medical decision extends over a broad area of situations from medical certificates of exemption, the period allocated to the treatment, a referral, to a better place on the waiting list, etc. The quality of the medical act can be a subjective or an objective thing. Because normally the bribery precedes the treatment, it is hard to assess the quality other than by comparing patients in the same situation, where one bribed and the other did not. In countries where bribery is very popular, the patient believes that the quality of the treatment is conditioned by his or her contributions. In this case, the patient tries to manipulate the medical personnel in order to obtain a favor, affecting the autonomy of the doctor. The medical personnel may condition the medical act with financial contributions. In this case, the medical intention is to trade medical goods (medical certificates, prescription of a specific medicine, organs for transplant, etc.) and services (operations, experimental treatments, etc.) for health. These intentions will contribute to a parallel black market for health care. In this case, the patient as a person is used as a means and the respect for her/his autonomy and dignity is endangered. The patient is caught in a life-threatening situation where the values of life and health are instrumentalized to obtain material benefits. In short, focusing on the initiator of the action, the act of bribery may deny the autonomy of the health personnel or may instrumentalize the values of life and health for the patient. An extended or established practice of medical bribery will create an invisible background/network power that will lend an air of normality to medical bribery (Searle, 2010, 155). The shared background norms are more or less conscious, not codified, and seldom explicit (Searle, 2010, 157). But they are behind the practice of bribery, and this sort of behavior will function without an express request from one side or another. Where and how do we draw the moral line that separates gratitude from bribery? For me, one of the essential criteria is the time and the spontaneity of gratitude. If someone feels the urge to give something back to the doctors, this should be a spontaneous and post factum act. Premeditation and the anticipatory sum of money change the whole situation. In the scenario of gratitude, Szawarski mentions that choosing the right token is a matter of tact and good taste, but he underlines that it


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preferably Euros), the Romanian equivalent of the Chinese “red packets” (Fan, 2007, 113). V. Possible Solutions to heal medical bribery

Policies of Care It is true that the physicians in the public healthcare system are underpaid. This fact is true for other categories of public sector employees as well. All in one, these public policies (health care, social protection, education) are inefficient or less centered on the real needs of citizens. They generate the feeling of a careless society (Held, 2006), and the fact is reflected in the massive migration movement toward countries with better care systems (Manea, Forthcoming). This clearly shows that for other public institutions, like the Romanian Parliament, health care is not a priority. The same inference can be made with regard to education. The fight against corruption, sustained and encouraged by programs of the European Commission, largely fails because of a misplaced strategy. The first steps of creating a legal infrastructure are certainly right in principle. But for restoring trust in institutions, there is no need to add more institutions. The government created new institutions as part of the national anticorruption strategy: the National Anti-Corruption Directorate (DNA) and the National Integrity Agency (ANI) (EC, 2012, 4). Yet the rather Orwellian name of these institutions transforms them into a kind of inquisitorial force in society. Adding to already existing


How can we have an ethical patient/physician relationship in a postcommunist country? How can we get rid of corruption in general in the affected societies? One answer is: let’s make the institutions trustworthy and rebuild the interpersonal trust. The institutional problem is a matter of public policies. For the case of health care, adequate financing programs will be a sign that the politicians care about the health of the population and about the dignity of the medical profession (Barnes, 2012, 147–203). This political effort cannot be done only for health: education and social protection should merge together in what I call policies of care. Policies of care can make institutions (starting with the political ones!) more trustworthy, and this may lay the basis of an ethics of trust. On this basis interpersonal trust, enforced by normal communication and no need for duplicity, can be restored as well. Education is another essential ingredient in rebuilding trust and understanding the moral ugliness of bribery. Education programs showing how the autonomy and the dignity of a person are lost in the act of bribery should convince the new generation about the value of trust and morality. Most of the Romanian population has a strong Orthodox orientation. Because of this influence, the Orthodox Church should sustain this educational campaign, and enforce personal good examples and morality on the parish level.

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institutions of punishment is not the solution. The institutionalization of justice and judicial independence remains an important issue for Romania, as pointed out in the EC Report:

The prosecution of high-level corruption cases is not a solution. This may be interpreted in various ways: (1) it may show that the anticorruption fight is successful, because even high-level people are not above the law, which is a good thing; (2) it may show that some exemplary punishments are used to scare the population, which might have some psychological effect for the society; (3) targeting high-level cases can be a façade to show off and convince others of the efficiency of the anticorruption fight, something used as part of political strategy. Punishing corrupt people may resemble a witch hunt, and this practice will itself generate more corruption. DNA (The National Anti-Corruption Department) indicted 167 cases against 415 defendants in 2007 and 233 cases against 1091 defendants in 2011. …Since 2007, DNA has indicted a former Prime Minister, a former deputy Prime Minister, a number of former ministers and members of parliament, numerous prefects, mayors, county councilors and heads of state-owned enterprises. In 2011, DNA indicted two members of parliament (MP) and one influential mayor of the then governing coalition and one MP of the opposition at the time. (EC, 2012, 12)

To report progress in the fight against corruption entails the risk that only notorious or politically undesirable people will be investigated and prosecuted. The old communist practice of denunciations weakened the public trust and the feeling of being part in a social contract that sustains the structure and the functionality of society. The new fight against corruption may have similar results. Multiplying institutions and laws is not a solution, and it might increase the socio-political inconsistency. Public administration in Romania was found to be the least effective in the EU, and the judicial system suffers from some of the same weaknesses. “Inconsistent jurisprudence is frequently reported in Romania and confirmed by stakeholders such as foreign investors, law firms and professional associations of magistrates” (EC, 2012, 7–8). The right way to fight against corruption is not to multiply institutions or laws for punishing people. This will only make room for more corruption, inconsistency, and mistrust. The EC Report for 2012 stipulates that now Romania is in a “climate where the vast majority of Romanians see corruption as a major problem.” The steps to meet the objectives of the Cooperation and Verification Mechanism of EC “have not yet convinced Romanians that


since accession, the judiciary has been able to affirm its independence gradually, in particular through the successful investigation, prosecution and trial of an increasing number of high-level corruption cases. …However, the Commission is concerned by the recent pressure exercised by members of the Romanian Government and senior politicians on the Constitutional Court: these are unacceptable interventions against an independent judicial institution. The Government and all political levels must respect the separation of powers. (EC, 2012, 5)


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An Ethics of Trust Medical bribery is a consequence of distrust in institutions, framed in the socio-historical background of communism. The communist system and ideology destroyed the public belief in institutions. After the fall of communism, the Romanian society believed in democracy as a solution to all political, socio-economic, and moral problems. But democracy seems not to be enough to restore a society and rebuild trust and trustworthiness, either interpersonal or institutional. The democratic legitimation of the new Romanian political class was not improving the morality of social and institutional behavior. “There is no necessary link between democratically legitimated policies and ethical requirements, green positions and public health” (O’Neill, 2002, 169–70). Intuitively, democratic legitimation should increase public trust. But O’Neill’s suspicion was right for the Romanian case: democratically elected politicians were not able to create public policies to protect minorities, vulnerable groups, and to restore the trustworthiness of institutions. Feeling betrayed by politicians, the population continues to build contingent interpersonal relationships in the social network, where trust is supplied and sealed by the “envelopes” of bribery. The postcommunist years of an all too slowly progressing reform of institutions deepened the social instability and pauperization of the former middle class. This fact was not contributing too much to pass over duplicity and complicity, or to rebuild the compromised and vulnerable selves that resulted from fear and dictatorship. Interpersonal trust was not reinstated. The budgetary cuts especially affected education, health care, and social protection, and this largely prevented the population from rebuilding their trust in institutions. The distrust in institutions is projected onto medical personnel


the situation is improving; with most considering that the situation has deteriorated.” A Eurobarometer report (February 2012) shows that 67% of Romanians consider that corruption had increased in the last 3 years (EC, 2012, 11, emphasis added). If corruption is objectified and made the main cause of bribery, then the natural ethical imperative will be to eradicate it. Here is the main ethical and political mistake that makes this phenomenon so present and so hard to cut off. It is possible to fight not the corruption, but the corrupt people. That is as if, in order to get rid of cancer, we killed the people with cancer, which is obviously wrong and not the solution. The new institutions created in Romania for prosecuting and punishing corrupt public figures are not the right solution. So again, why is bribery so common in ex-communist countries? It is interesting to mention that medical bribery seems to be present also in other countries of the Balkan area, like Greece (Kresge, 2012; Tremonti, 2012) and Turkey (Çobanoglu and Algier, 2004), which were not part of the Eastern bloc. They have unstable political systems as well as less social care.

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as well. The general public opinion is that low wages are a major reason for accepting bribes; and some cases of corruption may generalize the loss of trust. If people do not believe in institutions and in the way they can work, if they do not believe in other individuals as a part of a social contract in which everyone respects their engagement or role, then the insecurity and mistrust must somehow be reflected in different social practices and customs. The reflection of insecurity and mistrust is projected onto the practice of bribery. In this scenario, there is nothing that is specific for medical bribery, because it concerns the general function or malfunction of all institutions. Patient trust in physicians is a key element in health care (Goold, 2002, 79–81), but trust generally affects the relationship as a whole, not only on a personal, but also on an institutional, or cross-cultural level. Philosophers, sociologists, economists, and political scientists all tend to agree on this matter (Fukuyama, 1995; Kramer and Tyler, 1996; Saunders et al. 2010; Searle, 2010). Dirks (1999, 445–55), in the article “The Effects of Interpersonal Trust on Work Group Performance,” systematizes some operational definitions of trust as a belief about whether a partner is dependable, cares for your interests, is competent, and/or will act with integrity. Medical bribery cannot make a doctor competent, but it can create pressure to perform to her or his best ability. The moral integrity of the physician is short-circuited by the acceptance of bribes. So apparently the bribery cannot influence all the key elements of Dirks’ definition of trust. The only thing that can be influenced is the doctor’s care for a patient’s interests. Yet through the process of bribery a new sort of dependability is born: that of being together in an illegal and unethical practice. Paradoxically, although bribery is morally wrong, it creates its own set of moral rules, maybe similar—keeping the proportions—to the way moral rules guide the behavior of Mafia families. This fact leads to a further question: why two moralities? Is this a case of a public morality that is not trusted enough to be able to guide human conduct, and so is replaced by a private morality that works in particular cases like the medical context? Is the public morality still stained from years of public distrust? The trust issue connected with medical bribery in Romania is accompanied by a low trust in the reform of the public health sector (Manea, 2011, 61–62). If the whole mechanism of health care is not working properly, then the man-toman kind of agreement seems to be more trustworthy, even when built on an unethical basis. In a normal secularized society, to be a physician is just a job. There are professional obligations and state or private payment for it. To treat a patient is not a selfless or heroic act; so there should not be any special gratitude for a physician doing his or her job (Szawarski, 2005, 23–32). This fact can be observed in the asymmetric ethical behavior of patients in private and state supported health care in Romania. If a patient in Romania pays for private diagnosis or treatment, the officially required sums are not complemented by bribes. The trade is completed by the institutionalized rules of


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Education My analysis of medical bribery shows that it is difficult to isolate, objectify, and efficiently fight corruption. It has deep roots in mistrust, insecurity, and poverty, and those topics have to be addressed. A safer way to fight the general corruption in the public sector will be to have efficient institutions, which means well financed and ethical education. If the health system is decently financed, so that the health resources are sufficient for adequate care, the need for bribery will decrease. Of course, we can assume that there will always be people who want to jump the queue, but this will no longer be the rule; this will rather be the exception. The trust that everyone will have fair treatment partially depends on whether there are enough specialists, enough medicine, technical equipment, beds, etc. Scarcity of resources creates imbalanced powers between those with access to them and those in need of them. This observation is not only valid for the medical system, but everywhere else as well. Another good step forward will be to implement a national program of anti-corruption education, compulsory for every public employee, in place of Orwellian institutions. Education can form a better public opinion and in the end a better society. Teaching about the moral values disrespected in the bribery process and interiorizing rules of behavior are better solutions than the persecution of corrupt people. The psychology of the hunt creates fear and dissimulation, not conviction and social solidarity. My point is that if someone is corrupt and believes that it is right to procure some illegal advantages, that person will try “not to be caught” by those mechanisms rather than modify his moral values. Corruption is a wrong form of human behavior, and it should be tackled in its ontogenetic processes—how the corruption is created, how it works and thrives in a society, and not in its products—the people who have been corrupted. Educational programs about corruption should start


direct payment. In the context of private clinics, somehow the medical act is more regarded as a medical service between a service provider (physician, nurse, etc.) and a consumer (patient). Why is bribery not used in private clinics? There are various possible answers: (1) because new institutions are generally more trusted; (2) the clearly and openly announced prices for services may reflect a real and expected value of health care; and (3) private institutions’ internal rules may make the behavior of the consumer and the service provider more transparent and unequivocal. Another thing is that the new clinics look better; the patient has a sensation of comfort and general care, so this is reassuring and increases the trust that one will be honestly and adequately treated. Some of the big and underfinanced hospitals look so scary, that this décor may raise the patient’s concerns and a feeling of insecurity, and therefore the need to give something in advance for good treatment increases.

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VI. Conclusion Medical bribery is not a phenomenon specific to the Romanian culture, but it seems to be connected with postcommunist societies. I discussed the specific Romanian context of medical bribery by showing its roots and consequences, and in the last part I discussed some possible solutions to this deep and complicated social problem. The highly priced value of health, the asymmetric relation of power between physician and patient, and the low trust in institutions may generate bribery as primitive forms of individual contractualism between patient and physician, and as a guarantee of a well performed medical act. To rebuild interpersonal trust in a postcommunist society like Romania, where the practice of denunciation and duplicity was fatal, it will be necessary to restore trust in institutions (political, economic, and juridical). A national political strategy built on on the value of care, moral efforts of reinstating interpersonal and institutional trust, and a


very early, in the early school years, because children are very receptive to doing “the right thing,” especially as this is taught in schools. Further, it will be necessary to consider medical school courses about corruption, where the phenomenon is described, analyzed, and condemned as being opposed to moral values and to medical professionalism. The Romanian Orthodox Church, which seems to be an active and important social force (in 2002 census, 86.7% of Romanians declared themselves as Christian Orthodox), should assume a role in rebuilding interpersonal trust as an important moral value for community. Education against corruption and about the importance of trust can be included in the schools’ religious education curricula or in other social engaged projects of the Orthodox Church.3 Although an ethics of almsgiving is endorsed by the Orthodox Church, giving private money to doctors is not a guarantee that those doctors will use their extra financial resources to provide health care for poor people. There are lots of Romanian doctors doing charity work for poor people, but the moral imperatives of those doctors make them fight medical bribery (Ghirda, 2012). In the end, media may consider talk shows or campaigns showing the moral misery of corruption. If advertising is powerful enough to direct our consumer behavior, why shouldn’t it be efficient enough to influence our moral behavior as well? Not by showing handcuffed public figures, but by considering interviews where people may sincerely explain why they bribe and how they feel by being bribed. Or, especially for the medical topic, how parents may feel if their child is very sick and they have no money to bribe, and therefore have less hope that the doctors will help. All those situations may make the public aware of the ugliness of corruption and the abnormality of this behavior.


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national education program focusing on corruption will be the best solutions for fighting the roots of corruption. Notes

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1. Grant project (2010–2013): “Ethical aspects of the Romanian Medical Migration,” Postdoctoral Studies in the Field of Health Policy Ethics, implemented by “Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania, contract number POSDRU/89/1.5/S/61879. 2. As an example, the prices on the web page of a private hospital in Bucharest: http://www. sanador.ro/policlinici/preturi/. 3. For more information see: http://www.patriarhia.ro/ro/opera_social_filantropica/proiecte.html.

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