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The doctor’s dilemma

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It was not just yesterday, or the day before, that this subject was discussed. In fact, it was over a century ago that George Bernard Shaw, the famous Irish playwright, wrote the play, ‘The Doctor’s Dilemma’ that was first staged in 1906. It was published in book-form in 1909. It was considered a ‘problem play’ – a form of drama that emerged during the 19th century, dealing with contentious social issues which were debated on stage.

Would you believe that ‘The Doctor’s Dilemma’ was about moral dilemmas created by limited medical resources and the conflicts between the demands of private medicine as a business and as a vocation?

What do we see today? Not much seems to have changed between the early 1900s in England and the present day in Sri Lanka.

The whole nation now knows that of Dr. Maheshi Wijeratne, specialist neurosurgeon and consultant to the Sri Jayawardenepura Teaching Hospital (SJP TH), has been arrested, remanded and released on bail by the Chief Magistrates Court, Colombo, on a complaint filed by the Commission to Investigate Allegations of Bribery and Corruption (CIABOC). The arrest and remanding has disturbed a hornet’s nest, not only in the social media, amongst patients and elite societal circles, but also, significantly within the medical community.

What is disturbing to me, having been a medical teacher for nearly 45 years and a medical ethicist for many decades, is the lack of clarity amongst the doctors about Dr. Maheshi Wijeratne’s purported offence. This is the current doctors’ dilemma that I have been keenly observing and the main reason for this short essay.

According to reports circulating in the media, a few doctors have resigned from the SJP TH. An unexpected consequence of this has been, according to news items in the mainstream and social media, that doctors at SJP Hospital, and elsewhere, have refused to issue prescriptions to patients, or next of kin, for purchase of drugs, or other required items in the open market, for fear of being arrested. Is this reaction of some doctors in the Ministry of Health (MoH) a ‘healthy trend’? It is said that it is out of a genuine concern, and worry, that what they were doing routinely before, will now be construed to be “corruption”. Or, is it a collective response against the initiative taken by the CIABOC in solidarity with the plight of Dr. Maheshi Wijeratne? Or could it be a sense of ‘collective guilt’?

This fallout has/would jeopardise the health and lives of patients seeking treatment from SJP TH and other State sector hospitals.

Is this reaction by the doctors a reasonable reaction? Or is it an exaggerated knee-jerk response that would be seen by many doctors, as well as the public, as a surreptitious collective attempt in defence of Dr. Maheshi Wijeratne?

The Health Minister, Dr. Nalinda Jayatissa’s attempt to defuse the situation, and, maybe, prevent a nationwide move to embarrass the government and the Health Ministry, may have not have had the desired effect.

Understandably, the arrest of Dr. Maheshi Wijeratne came at a bad time when the antics of the former Health Minister Rambukwella and his family, and the then Secretary/Health, have resulted in them being repeatedly under remand custody and now being indicted on charges of unlawfully acquiring assets. The Rambukwella family case is much clearer and leaves little to the imagination and should not be used in comparison with the neurosurgeon’s case.

It also must be remembered that this is certainly not the first time that Dr. Maheshi Wijertne has literally “hit the headlines”. Her actions as a doctor, quite apart from being a neurosurgeon, regarding the Duminda Silva case, has been much criticised.

I believe that the issues of her serious ‘conflict of interest’ in this case would be a very useful vignette/case study/scenario in the teaching/learning programmes in medical ethics in the years to come.

To return to the issue at hand – i.e., the refusal of some specialists/doctors to give prescriptions for medicines and other purchases from “outside”, l think is counterproductive. The doctors seem to have behaved in an excessive demonstration of “protectionism”. A more circumspect, logical and analytical approach has been taken by the Association of Medical Specialists (AMS) in their letter to the Health Minister.

It must be remembered that specialists giving prescriptions to patients for purchases from “outside” is nothing new. And there have been no previous incidents of arrests and remanding for the same. Even though reliable stories are many in the past of specialists having “deals” with pharmacies, private laboratories and medical device providers.

We need to accept that the arrest and detention of Dr. Maheshi Wijeratne was an event that was waiting to happen for many years! It is an exceptional case and certainly not the norm. Why should honest, bona fide doctors and specialists, who have been genuine in their prescriptions, be perturbed? Surely, the CIABOC will not hound honest doctors doing their duty by their patients? Only those specialists who have been in league with private sector providers of special medicines (especially in oncology) and of medical devices (stents in cardiology) need be disturbed. They, certainly, have cause for concern. Their conscience will be troubling them now, since they are prone to be ‘next on the list’.

In this context, please allow me to digress, albeit briefly, into the worldwide phenomenon of ‘conflict of interest’ between the doctor and the pharmaceutical industry – the ‘Big Pharma’.

To understand the fundamental contradiction between doctors and the drug industry, one must realise that the medical profession has to place patients before self and should work for the maximum benefit of the patient (the concept of fidelity). Beneficence (doing good) or at least, non-maleficence (doing no harm) are other guiding principles. In addition, doctors today are expected to engage in the advocacy for patients – identifying their needs and working for developments in human and physical resource allocations for improvement in healthcare delivery.

In contrast, in the pharmaceutical industry, the guiding principle is profit; research and development of new drugs based on not need, but market demand and profit; research to be the market-leader for profit; service and charity with a view to societal acceptance and development of benevolent institutional images for profit. Some may consider this too harsh a formulation, but I believe this to be a realistic assessment of the present condition.

The relationship between the doctor and the pharmaceutical industry is necessary, unavoidable, but ethically controversial. Furthermore, the public have a right to be concerned if they feel that professional advice offered to them may have been influenced by financial or other benefits offered to medical professionals by commercial interests. The British Medical Association in its publication ‘Philosophy and Practice of Medical Ethics‘ observes that “The medical profession has an obligation to assure the public that treatment offered is appropriate and is justified by its intrinsic merit, uninfluenced by commercial or financial interests. This is especially important in relation to pharmaceutical products.”.

From the innumerable conversations I have had on this subject with many medical colleagues, I have the impression that they tend to believe that doctors are in control of the relationship between them and the drug companies. This sense of ‘well-being’ is near universal among the medical fraternity. In a study done in the Department of Medicine, University of California, in San Francisco, only 39% admitted that “industry promotions and contacts influenced their own prescribing”, but ironically, “84% believed that other doctors’ prescribing was affected”. In other words, the well-researched phenomenon of ‘actor-observer bias’ – that is, the belief that “others are more susceptible to temptation…” than you are – was clearly seen.

Some analysts of this relationship believe that it is the ‘naivety of the medical professional’ to not know that the marketing strategies of pharmaceutical companies are well researched. Paul Witkowski, Director of Pharmacy at Alliance, Ohio, USA, goes further. He says that “Every word and action of pharmaceutical sales representatives has been carefully choreographed and examined in front of ‘reactor panels’ in order to make the best impact of their product in the limited amount of ‘fact time’ they are permitted by their physician

customers. It is extremely successful; that’s why they do it.”

The doctors are showered with biased drug literature and free samples of medicines. This can be considered to relate directly to information transfer to the physicians. What is of greater concern is that ‘gifts’ are given to doctors to influence their prescription practices. These include anything from prescription pads, pens, paperweights to personalised executive diaries and annual subscriptions to medical journals and even to ‘Newsweek’ or ‘Time’ magazine; from sponsoring medical symposia and connected social events, organised by medical associations; with dinner invitations to 5-star hotels; to all expense paid trips abroad to attend international medical conventions.

These are but a few of the temptations that even ethical and honest doctors face in the ‘World of Global Medicine’ today. This, I believe, is the most predominant dilemma that all doctors, the world over, are confronted with.

But what about the deliberately dishonest doctors? Those without any empathy (or even sympathy or compassion) will exploit a patient and extract as much money as they can. These are the doctors who have ‘deals’ with suppliers and providers of medicines and devices. What of them? They are also a cross-section of any society. It is for the general public, the patients, honest and ethical doctors and also the CIABOC and other agencies to help society to separate the grain from the chaff. So that society will uphold the grain and discard the chaff from society. We need ‘whistleblowers’ within our medical community. This cannot be done if too many in the medical community, almost reflexively, become protective – irrespective of the specificity of a given situation. In our country, the Law, based on Roman Dutch Law and English Common Law, ensures that any accused is innocent until proven guilty. Hence, Dr. Maheshi Wijeratne will remain innocent until her case is completed and the judgement is given.

I strongly believe that we, medical professionals, need to be on the right side of the medical ethical divide even in the most difficult of circumstances, and not, in our short-sighted and anxious haste, be on the ‘other’ side.

We, as medical professionals, must not be seen as “protectionist” in the face of serious allegations of financial misdemeanors, corruption or frauds perpetrated against patients. Unconscionable margins (profits) between the purchaser and the seller is unacceptable in any commercial transaction. This becomes grossly unacceptable when doctors are sometimes seen to play intermediary ‘business’ roles between the two.

Let the Law take its course. It will take its time. The hype and sensationalism will soon die out. Dr. Maheshi Wijeratne has every right to her defence without too many flash bulbs and news-hounds. Life will return to normal. I hope where medical professionals are concerned, it will be a ‘new normal’. Will it come to pass? Or will it soon be ‘back to the status quo’?

To paraphrase a famous saying attributed to the Greeks, “The mills of justice grind slowly, but it grinds exceedingly small”.

I know that what I have stated here may not be taken too kindly by some of my professional colleagues.

So be it!

by Dr. Susirith Mendis ✍️
Emeritus Professor
University of Ruhuna
(susmend2610@gmail.com)



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Ranking public services with AI — A roadmap to reviving institutions like SriLankan Airlines

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Efficacy measures an organisation’s capacity to achieve its mission and intended outcomes under planned or optimal conditions. It differs from efficiency, which focuses on achieving objectives with minimal resources, and effectiveness, which evaluates results in real-world conditions. Today, modern AI tools, using publicly available data, enable objective assessment of the efficacy of Sri Lanka’s government institutions.

Among key public bodies, the Supreme Court of Sri Lanka emerges as the most efficacious, outperforming the Department of Inland Revenue, Sri Lanka Customs, the Election Commission, and Parliament. In the financial and regulatory sector, the Central Bank of Sri Lanka (CBSL) ranks highest, ahead of the Securities and Exchange Commission, the Public Utilities Commission, the Telecommunications Regulatory Commission, the Insurance Regulatory Commission, and the Sri Lanka Standards Institution.

Among state-owned enterprises, the Sri Lanka Ports Authority (SLPA) leads in efficacy, followed by Bank of Ceylon and People’s Bank. Other institutions assessed included the State Pharmaceuticals Corporation, the National Water Supply and Drainage Board, the Ceylon Electricity Board, the Ceylon Petroleum Corporation, and the Sri Lanka Transport Board. At the lower end of the spectrum were Lanka Sathosa and Sri Lankan Airlines, highlighting a critical challenge for the national economy.

Sri Lankan Airlines, consistently ranked at the bottom, has long been a financial drain. Despite successive governments’ reform attempts, sustainable solutions remain elusive.

Globally, the most profitable airlines operate as highly integrated, technology-enabled ecosystems rather than as fragmented departments. Operations, finance, fleet management, route planning, engineering, marketing, and customer service are closely coordinated, sharing real-time data to maximise efficiency, safety, and profitability.

The challenge for Sri Lankan Airlines is structural. Its operations are fragmented, overly hierarchical, and poorly aligned. Simply replacing the CEO or senior leadership will not address these deep-seated weaknesses. What the airline needs is a cohesive, integrated organisational ecosystem that leverages technology for cross-functional planning and real-time decision-making.

The government must urgently consider restructuring Sri Lankan Airlines to encourage:

=Joint planning across operational divisions

=Data-driven, evidence-based decision-making

=Continuous cross-functional consultation

=Collaborative strategic decisions on route rationalisation, fleet renewal, partnerships, and cost management, rather than exclusive top-down mandates

Sustainable reform requires systemic change. Without modernised organisational structures, stronger accountability, and aligned incentives across divisions, financial recovery will remain out of reach. An integrated, performance-oriented model offers the most realistic path to operational efficiency and long-term viability.

Reforming loss-making institutions like Sri Lankan Airlines is not merely a matter of leadership change — it is a structural overhaul essential to ensuring these entities contribute productively to the national economy rather than remain perpetual burdens.

By Chula Goonasekera – Citizen Analyst

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Why Pi Day?

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International Day of Mathematics falls tomorrow

The approximate value of Pi (π) is 3.14 in mathematics. Therefore, the day 14 March is celebrated as the Pi Day. In 2019, UNESCO proclaimed 14 March as the International Day of Mathematics.

Ancient Babylonians and Egyptians figured out that the circumference of a circle is slightly more than three times its diameter. But they could not come up with an exact value for this ratio although they knew that it is a constant. This constant was later named as π which is a letter in the Greek alphabet.

Archimedes

It was the Greek mathematician Archimedes (250 BC) who was able to find an upper bound and a lower bound for this constant. He drew a circle of diameter one unit and drew hexagons inside and outside the circle such that the sides of each hexagon touch the sides of the circle. In mathematics the circle passing through all vertices of a polygon is called a ‘circumcircle’ and the largest circle that fits inside a polygon tangent to all its sides is called an ‘incircle’. The total length of the smaller hexagon then becomes the lower bound of π and the length of the hexagon outside the circle is the upper bound. He realised that by increasing the number of sides of the polygon can make the bounds get closer to the value of Pi and increased the number of sides to 12,24,48 and 60. He argued that by increasing the number of sides will ultimately result in obtaining the original circle, thereby laying the foundation for the theory of limits. He ended up with the lower bound as 22/7 and the upper bound 223/71. He could not continue his research as his hometown Syracuse was invaded by Romans and was killed by one of the soldiers. His last words were ‘do not disturb my circles’, perhaps a reference to his continuing efforts to find the value of π to a greater accuracy.

Archimedes can be considered as the father of geometry. His contributions revolutionised geometry and his methods anticipated integral calculus. He invented the pulley and the hydraulic screw for drawing water from a well. He also discovered the law of hydrostatics. He formulated the law of levers which states that a smaller weight placed farther from a pivot can balance a much heavier weight closer to it. He famously said “Give me a lever long enough and a place to stand and I will move the earth”.

Mathematicians have found many expressions for π as a sum of infinite series that converge to its value. One such famous series is the Leibniz Series found in 1674 by the German mathematician Gottfried Leibniz, which is given below.

π = 4 ( 1 – 1/3 + 1/5 – 1/7 + 1/9 – ………….)

The Indian mathematical genius Ramanujan came up with a magnificent formula in 1910. The short form of the formula is as follows.

π = 9801/(1103 √8)

For practical applications an approximation is sufficient. Even NASA uses only the approximation 3.141592653589793 for its interplanetary navigation calculations.

It is not just an interesting and curious number. It is used for calculations in navigation, encryption, space exploration, video game development and even in medicine. As π is fundamental to spherical geometry, it is at the heart of positioning systems in GPS navigations. It also contributes significantly to cybersecurity. As it is an irrational number it is an excellent foundation for generating randomness required in encryption and securing communications. In the medical field, it helps to calculate blood flow rates and pressure differentials. In diagnostic tools such as CT scans and MRI, pi is an important component in mathematical algorithms and signal processing techniques.

This elegant, never-ending number demonstrates how mathematics transforms into practical applications that shape our world. The possibilities of what it can do are infinite as the number itself. It has become a symbol of beauty and complexity in mathematics. “It matters little who first arrives at an idea, rather what is significant is how far that idea can go.” said Sophie Germain.

Mathematics fans are intrigued by this irrational number and attempt to calculate it as far as they can. In March 2022, Emma Haruka Iwao of Japan calculated it to 100 trillion decimal places in Google Cloud. It had taken 157 days. The Guinness World Record for reciting the number from memory is held by Rajveer Meena of India for 70000 decimal places over 10 hours.

Happy Pi Day!

The author is a senior examiner of the International Baccalaureate in the UK and an educational consultant at the Overseas School of Colombo.

by R N A de Silva

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Sheer rise of Realpolitik making the world see the brink

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A combined US-Israel attack on Iran.(BBC)

The recent humanly costly torpedoing of an Iranian naval vessel in Sri Lanka’s Exclusive Economic Zone by a US submarine has raised a number of issues of great importance to international political discourse and law that call for elucidation. It is best that enlightened commentary is brought to bear in such discussions because at present misleading and uninformed speculation on questions arising from the incident are being aired by particularly jingoistic politicians of Sri Lanka’s South which could prove deleterious.

As matters stand, there seems to be no credible evidence that the Indian state was aware of the impending torpedoing of the Iranian vessel but these acerbic-tongued politicians of Sri Lanka’s South would have the local public believe that the tragedy was triggered with India’s connivance. Likewise, India is accused of ‘embroiling’ Sri Lanka in the incident on account of seemingly having prior knowledge of it and not warning Sri Lanka about the impending disaster.

It is plain that a process is once again afoot to raise anti-India hysteria in Sri Lanka. An obligation is cast on the Sri Lankan government to ensure that incendiary speculation of the above kind is defeated and India-Sri Lanka relations are prevented from being in any way harmed. Proactive measures are needed by the Sri Lankan government and well meaning quarters to ensure that public discourse in such matters have a factual and rational basis. ‘Knowledge gaps’ could prove hazardous.

Meanwhile, there could be no doubt that Sri Lanka’s sovereignty was violated by the US because the sinking of the Iranian vessel took place in Sri Lanka’s Exclusive Economic Zone. While there is no international decrying of the incident, and this is to be regretted, Sri Lanka’s helplessness and small player status would enable the US to ‘get away with it’.

Could anything be done by the international community to hold the US to account over the act of lawlessness in question? None is the answer at present. This is because in the current ‘Global Disorder’ major powers could commit the gravest international irregularities with impunity. As the threadbare cliché declares, ‘Might is Right’….. or so it seems.

Unfortunately, the UN could only merely verbally denounce any violations of International Law by the world’s foremost powers. It cannot use countervailing force against violators of the law, for example, on account of the divided nature of the UN Security Council, whose permanent members have shown incapability of seeing eye-to-eye on grave matters relating to International Law and order over the decades.

The foregoing considerations could force the conclusion on uncritical sections that Political Realism or Realpolitik has won out in the end. A basic premise of the school of thought known as Political Realism is that power or force wielded by states and international actors determine the shape, direction and substance of international relations. This school stands in marked contrast to political idealists who essentially proclaim that moral norms and values determine the nature of local and international politics.

While, British political scientist Thomas Hobbes, for instance, was a proponent of Political Realism, political idealism has its roots in the teachings of Socrates, Plato and latterly Friedrich Hegel of Germany, to name just few such notables.

On the face of it, therefore, there is no getting way from the conclusion that coercive force is the deciding factor in international politics. If this were not so, US President Donald Trump in collaboration with Israeli Rightist Premier Benjamin Natanyahu could not have wielded the ‘big stick’, so to speak, on Iran, killed its Supreme Head of State, terrorized the Iranian public and gone ‘scot-free’. That is, currently, the US’ impunity seems to be limitless.

Moreover, the evidence is that the Western bloc is reuniting in the face of Iran’s threats to stymie the flow of oil from West Asia to the rest of the world. The recent G7 summit witnessed a coming together of the foremost powers of the global North to ensure that the West does not suffer grave negative consequences from any future blocking of western oil supplies.

Meanwhile, Israel is having a ‘free run’ of the Middle East, so to speak, picking out perceived adversarial powers, such as Lebanon, and militarily neutralizing them; once again with impunity. On the other hand, Iran has been bringing under assault, with no questions asked, Gulf states that are seen as allying with the US and Israel. West Asia is facing a compounded crisis and International Law seems to be helplessly silent.

Wittingly or unwittingly, matters at the heart of International Law and peace are being obfuscated by some pro-Trump administration commentators meanwhile. For example, retired US Navy Captain Brent Sadler has cited Article 51 of the UN Charter, which provides for the right to self or collective self-defence of UN member states in the face of armed attacks, as justifying the US sinking of the Iranian vessel (See page 2 of The Island of March 10, 2026). But the Article makes it clear that such measures could be resorted to by UN members only ‘ if an armed attack occurs’ against them and under no other circumstances. But no such thing happened in the incident in question and the US acted under a sheer threat perception.

Clearly, the US has violated the Article through its action and has once again demonstrated its tendency to arbitrarily use military might. The general drift of Sadler’s thinking is that in the face of pressing national priorities, obligations of a state under International Law could be side-stepped. This is a sure recipe for international anarchy because in such a policy environment states could pursue their national interests, irrespective of their merits, disregarding in the process their obligations towards the international community.

Moreover, Article 51 repeatedly reiterates the authority of the UN Security Council and the obligation of those states that act in self-defence to report to the Council and be guided by it. Sadler, therefore, could be said to have cited the Article very selectively, whereas, right along member states’ commitments to the UNSC are stressed.

However, it is beyond doubt that international anarchy has strengthened its grip over the world. While the US set destabilizing precedents after the crumbling of the Cold War that paved the way for the current anarchic situation, Russia further aggravated these degenerative trends through its invasion of Ukraine. Stepping back from anarchy has thus emerged as the prime challenge for the world community.

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