- V.Manickavel. M.D.
College of Medical Sciences-Nepal,
Kathmandu University, Bharatpur, Chitwan, Nepal.
In the human rights issue and in the charter of equality of humanity freedom to make independent decision is an important factor. In the history of humankind, several important hurdles had been passed to form the present UN charter of rights and the same in many nations. The freedoms to make independent decision and to capacitate a person to make a decision are some of the topics had been discussed elaborately in the academics and in the political circle.
However, the freedom of expression varies widely in different cultures as it is largely determined by the traditions of the family or society. Sociologists and other social scientists had widely analyzed the freedom of expression or lack of it in many of the social institutions like marriage, death etc., Freedom of expression should not be considered always, as a sign of progress as contradictions do exist, for example, western society members show more autonomy in many aspects including in the selection of mate. However, autonomy in the expression of grief is not allowed in that culture. However, in many eastern and other societies autonomy in the selection of mate and in other aspects is very much regulated, but, not in the expression of grief.
Further, biologists and other scientists had shown that primate growth in terms of learning to become completely independent of other members is slow, compared to other species. This slow development do impede the attainment of 'full freedom' and this may be the reason that many species including primates and humans live in families, groups, and societies for fuller social development. Autonomy in the free expression of some human behavior e. g. Anger/ rage is always restrained for the benefit of or to protect their fellow members of the family, group, society or nation but some behaviors are encouraged for fuller expression e.g. Love that is universal and spreads beyond all boundaries. For a culture to evolve, a certain degree of dependency and non-expression of individual overriding rights over somebody is essential. Autonomy thus should be considered only as a relative concept rather than as an absolute with definite conditions. Farther, the concept of autonomy is not a modern one and it has been in existence from the early history of human kind but, might not had the same universal applications as it is in the present time.
I would like to explore here, the expression of autonomy in the clinical decision making in the Hindu society. I will be looking at the situations both in Nepal and in India. The former is the only Hindu nation in the world and the Hindus largely populate the other. In both these nations majority do practice the traditional Hindu culture. However, I am going to restrict myself with two-aspect (i.e.) trust and consequences, for this discussion.
One of the major beliefs of Hinduism is reincarnation, where, one believes that one will be reborn again after the termination of this birth as a result of their actions thus, death actually is not the END of a life but a MEANS to get another birth.
The body is considered as a vehicle to cross the ocean of birth and rebirth (SAMSARA). It is a blessing to have this birth (i.e.) this body to realize this truth. So, one has to take proper care of this body. However, the body is not permanent but are discarded, as the 'snake sloughs of its skin as it grows' or as discarding an old shell and occupying a new shell. This truth of impermanence of the body leads one to loosen the attachment on the body and to realize that grieving is not necessary for the loss of this body. This knowledge, further, gives the clarity not to entertain the futile attempts of avoiding inevitable death, so one can prepare one-self for that. This view of death is not unique in Hindu society but seen in many societies also.
A mother of a native Canadian child who had liver transplantation for a congenital liver disease decided to stop the treatment of steroids and other anti-rejection drugs because of the suffering of the child due to the treatment. But the Canadian court decided to take custody of the child to continue the treatment of the child. In the court, the mother pleaded to have the freedom of having not to treat the child so that, "the butterfly (child) should have the freedom to fly (death). Instead trying to hold the beautiful butterfly tightly and not letting it loose to go but making it loose its luster and the scales on the wings in the struggle to free and die".
A patient in the traditional health care usually goes to the health care provider with TRUST. This trust results in hope and gives the patient and health care provider a positive out look in the treatment process and a kinship between the patient and the health care provider normally develops. In a homogeneous society, where transparency is more common, this type of trust was easily cultivated. However, in the After Globalization Era (AGE) there is increasing threat to homogeneity. There is more alienation among the members of the society, as it becomes less homogeneous. Subsequently this alienation brings fear among the members leading to mistrust between the members of the society. Inspite there was less alienation among the members of the Hindu society in the Before Globalization Era (BGE) the caste hierarchy induced fear in the suppressed some sections of the society. Alienation tend to increase as interaction between different culture and languages increased. Similarly, more of one kind knowledge or knowledge of different kind increases the degree of alienation. The alienation as it becomes wider it created more fear among their members. This sense of alienation increased in a faster rate in AGE building up mistrust in many of the institutions.
In the health care institution, (i.e.) in the modern Medical care, patients face health care providers of different culture, language and others. This encounter of strangers elicit fear in a situation, where, trust has to give hope, but, hear leading, may be, to mistrust. This situation in the modern health care stresses the need of bioethics, specifically the prime principles, viz. Informed consent, autonomy, and truth telling.
The Hindu society faced the question of trusting the aliens by their central axiomatic belief, That, every action has consequent reaction(s) and subsequent series of chains of reactions. This cultural belief that every one is held responsible for one's own intention and action, makes one to act more responsibly as the universal dictum stresses also that, "Do not do to one that you do not want that from anybody". To the Hindus this belief is universal and not only limited to the Hindus but apply to everybody including aliens. This makes one to trust every one, since no body will harm anybody intentionally. As the other knows, that one has to face the consequences of their action. This belief is not a unique belief of Hindus alone. This is true in many other eastern religions and in the Judeo-Christian traditions. However, Hindus believe that all actions bring consequent actions not only in this life but go beyond one's life carried on to the next life to face. Further, the consequences elicited by the actions that could not be faced in the present life determine the life in the next birth. Therefore, Hindus always remain conscious of the consequences of their actions as these actions constantly architect their home future births. This transcendent thinking of going beyond one's life and taking responsibility for the consequences, does, make a Hindu to act more responsibly.
The complete trust on the strangers in many ways is seen in the clinical treatment decision making in these societies. The patients first trust the knowledge of the health care giver. Further, the patient allows the health care giver to study the patient's sickness, to decide the treatment, and to administer. Nevertheless, if the health care giver decides not to execute the paternalistic freedom given by the patient, then the patient depends on the family, or community members to make the decision about the treatment on behalf of the patient. This decision is fully accepted by the patient on the trust that decision-maker has made a responsible decision on behalf of the patient. Because the action of deciding on behalf of the patient also created consequent actions to face by the other. This belief, in health care giver channels the health care giver to make the right decision for that particular patient at that particular time. The bioethical principle of autonomy, as discussed in Western bioethical literature and in practice, views paternalism as the intrusion of autonomy. This paternalism is practiced in this culture, as, the health care giver taking full responsible decision for the patient based on such transcendent belief on the consequences. This may be construed as paternalistic attitude of the health care giver. However, the paternalism practiced in this way is not considered as an intrusion in one's autonomy. Further, this belief in this society does not elicit some of the legal arguments of competency in making decisions for mentally compromised and age-wise compromised persons.
More over, this cultural determinism is not a restriction on the patient in making the decision but it is a type of freedom to trust somebody to make the right decision for somebody else. Another point to consider here is that sickness makes the patient weaker. Further, the patient's own anxiety about the sickness keep the patient in a position not able to make the right decision. Normally, the treatment and its consequences are not comprehended fully so the decision by a trustworthy decision-maker is considered as the best alternative. This trustworthiness is brought here as the product of the cultural determinism.
A positive argument had been put
forward here about an aspect of cultural determinism. The feeling
of alienation can occur due to several reasons in any community,
is unavoidable. In a Hindu society, color was one of the reasons
to bring alienation. In the modern industrial society, wealth
is one of the reasons of alienation. When a resource poor patient
approaches a modern health care set-up the patient invariably
feels alienated by the several technological machines and the
rich health care giver them selves. In this paper I wanted to
discuss how alienation and its effects are handled in a Hindu
The author would like to thank the College of Medical Sciences-Nepal for the support and to Prof. R. Ramaswamy for his enthusiastic encouragement and to Mr. G.Veerapandu for his efficient Technical help.