Few reflections on medicine and society

                                                       

Having written a reflection on my Alma Mater for its student run magazine, and upon receiving positive feedback, I have been inspired to write a second piece - this one less about the hospital itself but about the reflections it drove within me.

Our world view is often linear at times, in that we expect certain actions and traits to yield specific results, just as we expect a little seed to produce the mighty Banyan, this is an effect of the European Enlightenment which purported a narrative of progress through development. Even as European powers colonised and decolonised the rest of the world, their world views and administrative mechanism remained.  Even a cursory study of peoples before will reveal that their view of life was static as in we have lived as our forebears always did, cyclical as in we go through phases sequentially, or decadent in that we have come forth from a golden age and are declining since. While it will amount to hubris to simply ascribe greatness to one world view, we can remark that many of our modern anxieties are in reaction to this progressivistic thought process. 

Why is this reflection necessary? It is, since our world views inevitably colour our practice of medicine, being the dual scientific and humanistic pursuit that it is. The most important topic for many religions and philosophies is death. Death is central to the practice of medicine, in that many ways modern medicine views it as antagonistic. In his ‘Medical Nemesis’, Ivan Illich notes that with medicine, death often ceases to be the psycho-social phenomenon it is construed to be, but becomes the point beyond which modern technologies fail to maintain life.

Working in an ICU is beyond doubt deeply rewarding. Yet, it doesn’t take long to question the purpose of what we are doing. The sudden mushrooming of critical care as a specialty raises these questions. The process of death - the slowing of the heartbeat, the weakening of the pulse, the loss of consciousness has undoubtedly been the same, ever since the first shrew dared to step out of water for the promise of land. Yet, by monitoring each of these phenomena, medicine seems to be defining entirely new stages in the process of death. 

This isn’t to sound overtly nihilistic either, there are many cases where good ICU care yields deep satisfaction, for example, a child with severe dengue, or a young girl with severe burns. But by promising solutions for the process of death itself, medicine is being driven to techo-solutionism. This is even more worrying since medical debt is the leading cause of poverty in India. The inevitable response of society has been to question the meaning of life, with concepts such as euthanasia and DNR gaining proponents. 

At its deepest level, death is what provides meaning to life - we love something precisely since we might lose it later, and by raising the question of euthanasia, human beings are fighting back to express agency over something that has been commoditised, something that never should have been. The true issue here is however not knowing when to draw lines, where exactly do we stop intensive care? It seems practically impossible to draw up guidelines for something as intangible as life. 

The second, more entrenched dealing with death is the acceptance of it. Years ago, I remember having deeply involved conversations on breaking bad news. One takeaway of this conversation is that medical students today are less exposed to negative outcomes, such as death at home, and are hence less understanding of what it truly connotes. Selection of students for medical courses, for several purposes, has become based on standardized testing. The students who get selected are in many cases invested in the sciences, but lose on subjective and emotional intelligence.

For eastern societies, the notion of home and hearth being a place of happiness and comfort. Of course, in India, family and community are very important, but even today, we notice that elders at home crossing the age of 90 do not engage in what is commonly called pampering. One was likely to have many siblings at birth, and was likely to lose one or two. The same goes for their children and cousins. Further, the notion of progress and acquisition was also limited. All my siblings were likely to have a life similar to mine, and the people down the road, one similar to their parents. The focus on entrance examinations and the proverbial checklist is a result of the sharp fragmentation of people, and rising economic solutionism - the notion that issues can be solved.

But most importantly, the need to protect, that we so often find today, was absent. While parents today might allow their child to attend a marriage, they consciously attempt to avoid any contact with even the concept of death. In an age when taboos are being challenged, death has become the new taboo. It is not surprising then, that doctors coming from such sharply individualistic backgrounds problematise death and see it as ‘solveable’. How such a person breaks bad news will be vastly different. My observations with doctors in internship has in some ways supported this concern. It is wrong to label people as unempathetic, but yet, the emotional unraveling of the process of death, and bad news in general, seems to be more mature and wholesome, something that the world of ruthless optimization does not offer.

The third is also concerning my own personal experiences. The narrowing down the family structure has in many ways opened a new line of comparison. A parallel between the older Indian, the one living in a community and the Indian who lives a more society driven life, with siblings and cousins may be drawn here. When one grows up, she is more likely to don various roles. For instance, the girl naturally assumes such roles as the doting elder sister, the bully, the younger sibling needing friendship. Hence the problem of difference too is solved. That kid in the corner who doesn’t speak much, the boy who wants to run to the kitchen after school, the girl who wears her spectacles too low - these social archetypes become normalised and natural - there is no need to correct them.

The oft-raised issue of intrusive parenting, is an offset of this. In a modern nuclear society, parents are more likely to don all these roles, and hence the one kid needs to be perfect. Medical education and medical practice lose their previous meaning , hence the excess focus on a better course, a better speciality and so on - the lessening of someone with perceived lesser outcomes. The loss here is the emotional comfort that one gains in being vulnerable - a trait that is seen as unnecessary. Indian literature celebrates willful surrender to a higher force - something that needn’t necessarily be abstract. Children from such more familial backgrounds handle these dynamics very well, owing to their switching of roles.

This is where medical relevance becomes really important - the experiences of the wise have shown that the voluntary assumption of a greater responsibility is what provides satisfaction, and not mere acquisition, particularly in a country like India, where famine and penury are no longer the main issues. Staying in the ward for an extra hour, holding someone’s hand as they walk to the door and writing a report for someone else - these are very common behaviours in medicine, and cannot be explained by a purely progressive world view. This assumption of responsibility comes paired with the need to feel vulnerable in a safe manner. For many it might be because of the bond they share with their senior colleagues, but for many others it might be medicine itself, a pursuit that never stops giving.

A common remark that can be raised against me here is that all I am offering is a lament at the changing times, and perhaps that’s all it will be. With dropping fertility rates and commercialisation, what can we really do? To me, that is not a very healthy way to frame the problem. A common parable quoted in India is that of the mango orchard. One may stand outside, count the mangoes and even weigh them, but to truly experience it, requires us to eat the fruit. Despite all its failings, doctors pursue medicine because of the reward that it brings - the emotional component not being the least. In addition to accounting for our material needs, medicine, through its paired offering of vulnerability and responsibility offers us a way to self-actualise. It is my conviction that this reflection can alleviate, at least on an individual level, many of its shortcomings. This profound realisation is supported by the observation that what endears people to you is not intelligence, but character.