There is obviously differing medical advice given to Anwar Ibrahim. I am not particularly an 'Anwar supporter' (whatever that means, pejorative or otherwise), and neither have I categorically stated that he simply must go overseas for treatment and nothing else.

When discussing a patient's and prisoner's medical rights, Malaysian doctors should not feel personally slighted by the content of this sort of discussion.

Having had the privilege of examining Anwar together with Malaysian doctors at Hospital Kuala Lumpur (HKL), assessing his investigations, and having routinely taken consent from patients for more than 25 years, I feel I am in a position to comment further, albeit somewhat provocatively.

Proper disclosure to the patient whether benefits outweigh the risks of any medical treatment is now becoming a duty required of the treating doctor, at a standard that the law courts may well take upon themselves to decide.

The quality of disclosure is no longer being left to the dictates of the medical profession. It will not be long before Malaysian doctors, like some of their overseas colleagues, will be legally required to be transparent and specific about their personal surgical outcomes, and not rely on favourable risk statistics that originate in centres of excellence.

Sometimes (as with vaccinations and appendicetomies) the balancing of these equations is much less grey as it is with spinal surgery. Whichever way the doctor may perceive the risk-benefit scales to tilt, the power to decide ultimately remains with the adequately informed patient, influenced to varying degrees by his closest ones.

It understandably creates physician angst when a non-compliant patient rejects what a doctor perceives to be 'reasonable' medical advice. Whatever the underlying beliefs or fears that inform such refusal of advice, often the only route for the dismayed physician to take is to discharge his/her legal and ethical duties, and move on, perhaps with some cynicism, but with a clear conscience.

On occasion, there is a legal and moral obligation to inform the authorities about non- compliance. Mostly, a doctor can simply do no more that jump up and down stamping his feet, declaring something along the lines of: 'I have come to my own opinion as to what is required ... and my belief is that it is in Anwar's best interests to have his surgery urgently, and this would mean here in Malaysia, and this would mean open surgery.'

Well, while it is commendable for a surgeon to be assertive in offering his learned version of sound medical advice, this reads like the seeds of medical paternalism, if ever.

The comparison of Anwar's current wariness to the unflinching belief in Malaysian cardiac services shown by Tok Guru Nik Aziz (and indeed that of former Prime Minister Dr Mahathir Mohamad), is a tenuous one.

Both were powerful and free men at the time of their illnesses, confronted with imminent risk of cardiac threat. It is often ignored that in the case of the latter, the temporal pressure for a decision about critical surgery certainly precluded any dithering over overseas treatment options.

I will even venture to comment that (by judging its reputation entirely by anecdotal evidence from local surgeons and anaesthetists) with due respect, the quality of spinal surgery at HKL where there is no 'full-time' spinal surgeon, is not comparable to the world-class cardiac services at the National Heart Institute (IJN).

With that limited (perhaps biased) available information, it is understandable that Anwar and his
advisors may have had to conclude that the best possible treatment for his spinal condition would not be obtained from the hands of otherwise competent generalist HKL orthopaedic or other surgeon.

If he could however retain the right to choose to have surgery in a private hospital in Malaysia, what of his right to have it done abroad at a special spine centre?

It is unfortunate that the monumental wrangling surrounding Anwar's case has been medicalised. The acceptability of local treatment options may well have nothing to do with what is really going on.

Again, I will state - the decision is not 'medical' any more.