By Pinghui Xiao and Hong Hong.
On July 19, 2024, Li Sheng, a cardiologist from the First Affiliated Hospital of Wenzhou Medical University was stabbed by an irate relative of a patient. Li suffered multiple serious injuries, including to his liver, intestines, pancreas and abdominal aorta. Despite emergency treatment, he died on the same day.
The incident has garnered significant attention on Chinese social media, due to its severity and because it involves medical professionals, who are often viewed as central figures in debates about healthcare issues. Immediately after the incident, the National Health Commission, as well as the National Healthcare Security Administration, and the Chinese Medical Doctors Association, among other healthcare-related institutions, issued statements strongly condemning the killing.
Li being stabbed to death at the hospital was the latest in a string of attacks on medical staff by patients or their relatives; two months prior, another man whose son had died due to unsuccessful treatment at a hospital in Yunnan, attacked patients and medical staff with a knife, resulting in 21 injuries and two deaths.
Attacks on healthcare workers, mostly by angry relatives of disgruntled patients, are not new and have been increasing in recent years. Incidents of violence against healthcare workers have been attributed to multiple factors related to medical treatment, including financial pressures, perceived inadequacies in medical care, and emotional responses to patient outcomes, particularly in cases of unexpected deaths. A Chinese media outlet sampled 295 violent incidents targeting healthcare workers between 2009 and 2018 occurring in mainland China. It found that 362 medical workers were injured, 99 medical workers were attacked by patients with knives, and 24 doctors were killed.
Ethical-legal Considerations
The tragedy of healthcare workers being killed by patients or their relatives raises significant ethical and legal questions. Workplace violence against healthcare workers is becoming a growing global concern in healthcare systems.
Despite decades of research and interventions, violent incidents against healthcare workers in China continue to increase in both severity and frequency. This trend is particularly concerning given that doctors are generally held in high regard worldwide for their crucial role in saving lives. These tragic events typically occur in healthcare settings where doctors are actively trying to provide care. Such incidents raise critical questions about the persistence of violence against medical professionals and the measures needed to prevent it. This situation highlights the need for a broader discussion on the respect and protection afforded to those in life-saving professions. It underscores the importance of addressing the underlying factors contributing to these violent acts and implementing effective strategies to ensure the safety of healthcare workers.
In the case of Li, his attacker took his own life by jumping from a building after the incident, which is still under investigation. Though the actual motives behind this tragedy remain unknown, the incident has fueled calls for stricter laws to keep violence away from doctors in China. Indeed, China introduced in 2019 laws aimed at preventing violence against medical professionals, but these laws do not seem to prevent tragedies like that from happening. Clearly, more research is needed to reveal the root causes and countermeasures to reverse tragedies of this kind.
Previous and ongoing research reveals that the following deeply-rooted problems may help explain the above ethical and legal questions.
First, there is a deeply-rooted public investment deficit in China’s healthcare system. As one of the most industrialized developing countries, it has relatively low investment in health care. For instance, according to WHO data, health expenditure as a share of GDP for China in the year of 2021 was 5.38 %, which was roughly on par with the average level of low-income countries at 5.25 %. In comparison, in the US, the number was 16.57, triple that of China’s. So hospitals are receiving limited public financial support, which forces them to obtain further funds through commercial operations. Though China implements a universal health care system, many if not all treatment plans from doctors – depending on illnesses and severity – are not fully covered. The above factors combined incur tremendous financial burdens for patients.
Second, China has long been inflicted by imbalanced distribution of medical resources. Medical resources are unevenly distributed in different regions due to economic gaps between the western, central, and eastern parts of China. Evidence shows that especially residents in rural areas of China, concerns about the quality of local primary healthcare, often bypass these facilities to seek treatment at higher-level hospitals. This leads to urban tertiary hospitals being more likely to be flooded with patients, who avoid local primary care facilities to visit these well-equipped larger hospitals. This makes urban tertiary hospitals crowded, creating huge burdens for them to overcome. As data shows, the higher the level of the hospital, the higher the frequency of reported violent incidents in China. Seventy percent of the violent incidents reported in the past ten years occurred in tertiary hospitals.
Third, there is growing mistrust between burnt-out low-waged doctors and resentful overburdened patients, which further strains their relationship. Excess patients put significant pressure on doctors. Doctors in tertiary hospitals in particular, significant pressure and suffer from burnout. This makes doctors unable to provide enough quality care to patients. On the other hand, doctors deserve more respect and decent working conditions, which is not the case in China. As with the rest of the world, Chinese doctors have to have many years of formal education with limited social lives during that time. However, they are not all that well respected these days nor all that well paid, although they certainly are respected for the most part in most of the other developed countries. Doctors in China earn relatively low wages compared with their western counterparts, which leads to some doctors accepting monetary gifts (“red envelopes”) from patients to supplement their wages, particularly in some hospitals. Resentment can be aggravated when patients have to pay bribes to guarantee good services.
There seems to be a deadlock when it comes to healthcare provision in China. Patients in China often have high, and sometimes unrealistic, expectations for medical treatment. For instance, a patient from Guangzhou had received a dental crown 25 years earlier and found it discoloured in 2016. He unexpectedly visited his dentist seeking compensation. Upon refusal, he followed the dentist home and violently stabbed him to death. Emotions can run high in healthcare settings, often due to concerns about the cost and availability of medical services. Meanwhile, quite often, there is a lack of effective complaint mechanisms to raise disputes, and hence some patients feel like they have become targets of exploitation and resort to violence.
All the above factors combine to contribute to poor doctor-patient relationships, from which violence ensues.
To respond to this situation, China should address the aforementioned root causes, but also exert every effort to prevent healthcare workers from immediate workplace violence. A number of measures have been suggested, such as installing high-definition surveillance cameras in key hospital areas and establishing an emergency alarm system to ensure a rapid responses to attacks. Additionally, hospitals are also suggested to hire more professional security personnel, carry out regular security training and exercises, and improve their overall security and prevention capacities.
Authors: Pinghui Xiao and Hong Hong
Affiliations:
PX: Senior Lecturer of Law School of Guangzhou University, China. His research is focused on health law, food and drug law.
HH: Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University
Competing interests: None declared