Ethics tries handling inner conflicts scientifically/spiritually
Manu Kothari, Lopa Mehta
“Ethic: from ethos, character, L ethos, adopted by English especially in sense of ‘character and spirit of a people’. Intimately akin to Gr ethos, custom, Skt. sva-dha one’s own doing or action; sva self (cf suicide) + dha to self.” (1)
“Sva-dha:self-position, self-power, inherent power, custom, rule, ease, comfort, according to one’s habit or pleasure, spontaneously, willingly, easily, freely, undisturbedly, wantonly, sportively.” (2)
Words reveal their meanings to those who establish intimacy with them, as the bride unveils her face only to the beloved one.
The Rig Veda 10.71.4
The above etymological preamble is inspired by Aldous Huxley’s lament in The perennial philosophy (3) that humankind is indifferent to the genuine meaning of terms. For example, the word “love” is used to describe two characters embracing rapturously on the screen, as well as the concern felt by Buddha, Christ or Gandhi for the whole of humankind. This confusion regarding the use of words arises from “the lack of a suitable vocabulary and an adequate frame of reference, and the absence of any strong and sustained desire to invent these necessary instruments of thought. …. Many thoughts are unthinkable apart from an appropriate vocabulary and a frame of reference.” (3). Unless “Ethics” is eusemantically analysed and synthesised, much of our effort to be ethical is likely to be unproductive.
The Oxford companion to philosophy (4) gives 23 subsets of “ethics”, among which are ethical naturalism/objectivism/relativism/subjectivism. However, through all these subsets runs the underlying refrain of “transactional” because ethics pertains to the interaction between two or more people, the encounter between a patient and a physician being one such. At the very outset, we may cite Swami Dayananda Saraswati (5), considered by many to be the guru of Vedanta. His panchreston, golden rule or mahamantra on ethics is “Do unto others what you would have them do unto you and do NOT do unto others what you would not like.” This is an echo of what the Bhagwad Geeta, the Jewish Talmud and Eric Ericsson (6) preach. The whole essence of medical ethics may be summed up as the physician’s readiness to put himself/herself in the position of the patient. Would a physician question himself/herself as to whether he/she would have his/her treating physician act rude, hurried or dismissive, or overcharge, or diagnose/treat “pragmatically”, and so on?
Park and Lees (7), after an extensive survey of breast cancer, concluded that many a breast cancer was pragmatically diagnosed and treated with the idea that the breast, however normal, was better off in the theatre bucket than on a woman’s body. Bloodgood (8), in a retrospective study at Johns Hopkins, discovered that as many as 35% of breast cancers were diagnosed for the heck of it, the breasts having been histologically normal. People who are thoroughly asymptomatic and at peace with their “blocked” coronaries meet much the same fate when their coronaries are prophylactically bypassed and/or angioplasty and stenting is performed (9), with the invasive coronaryologists claiming that they have been snatched from the jaws of imminent death. Doing better and feeling worse: health in the United States (10) is a 1977 Rockefeller Foundation tome that details how the USA, which spent an average of $8–10 billion a year on health in the 1970’s, is now spending $5 billion a day, with doctors and the establishment “doing better” and the patients “feeling worse”. Wildavsky (10), a New York physician, states that medical science is helpful in just 1 out of 10 maladies.
How come, despite Norman Cousins having officially chaired humanities at Stanford and Sunil Pandya having laid the foundation for the current IJME, Medical Ethics has taken a nosedive, regardless of IJME, and the global movement towards some ethical sense? How come Norton Hadler (11), in The last well person – how to stay well despite the health-care system concludes that “the institution of medicine is ethically bankrupt.” Ethics, ethics everywhere, a note which hardly a medical soul is ready to sing.
Why has the game gone colossally awry, both nationally and globally? Has medical ethics metamorphosed into some new mammonic avatar, designed more to serve the establishment and the shareholder than the patient? Words remain true to themselves and do not change; however, our attitude to them does. It is our attitude that we must question to find a way out.
Ethicality is judgmental and the judge resides in the very person whose words and actions are to be judged. Objective ethics asks the compassionate “right brain” to question what the proactive “left brain” does. As Monier-Williams (2) says while expanding on sva-dha, this occurs from within, is voluntary, spontaneous and sportive, without any external guide or pressure. The right brain commands: “Treat the patient exactly as you would choose to be treated.” However, if this judge has been bought over by the powers that be, there are no pricks of conscience, no hard pillow at night, and no regrets whatsoever.
Hitler and Stalin ordered genocides with a nonchalant self-righteousness and Goebbels and Beria followed suit, almost with smug delight. Much the same way, a modern medico does not have any pangs of conscience, and hence the mayhem keeps growing exponentially.
Bertrand Russell (12) bemoaned that the modern educational system teaches how to do, but not how to think or reflect. It breeds a knee-jerk response to a finding or any assumed or actual pathology, executing genu-reflexopathy on a benumbing scale. The medical curricula are overloaded with catalogues of facts and taught by shallow faculty. At conferences and in the accompanying press releases, there is perpetual talk of “modern trends, recent advances, progress” and so on. Conferences are not convened to ponder over regression in medicine. Journals, too, do not discuss this issue. Science from scientia (13) is to know and not to do, while technique is all about doing and provides its purveyors with a cocksureness that could never doubt itself when it comes to doing. Statistics then becomes its able helper: “The cardiovascular surgery community speaks of benefit to the patients who have multiple blockages in multiple vessels, but the basis for that claim is marginal. It derives from a reanalysis of the data from the classic trials ….. a secondary analysis’ that is an indefensible statistical manoeuvre.” as Hadler puts it (11). Hadler also cites James Mills who referred to such revision as “data torturing” and explained: “If you torture your data long enough, they will tell you whatever you want to hear.” (14). Hadler may sound pessimistic, but the Russian proverb (15) comes to his rescue in declaring that a pessimist is a well-informed optimist.
In its ostensible pursuit of technological excellence, modern medicine has quashed the last vestiges of scepticism, which is the birth right of the evaluating and questioning right brain. The Gottingen University oath prescribed to a new entrant – “You are here not to worship what is known, but to question it” – has been consigned to history. Mephistopheles is having the last laugh at the expense of Dr Faustus, who is not an ethical moron but has willy-nilly chosen the path of ethical bankruptcy to effectively snuff out any questioning by the right brain.
We thus have the paradox of a not-too-remote Oslerean past when ethics was not talked about but practised fairly well, and the current scenario of conferences, courses, journals, books and soon curricula and examinations on ethics, but hardly any ethics in practice. “The fault, dear Brutus, is not in our stars, but in ourselves.”(Julius Caesar, Act I, Sc 2:140-1). We are forgetting our faults.
Subjective ethics, or the violation thereof, is best illustrated by the way a modern socialite eats and drinks. As Desmond Morris says in Manwatching (16), “Here, there is enough food for those who are not hungry, and enough drinks for those who are not thirsty.” At a party, a hotel, or at home when you have been over served and a gentle inner whisper of satiation urges you to stop any more import, the urge gets overruled to spawn the science of bariatrics. Much of global starvation is not because of the unavailability of food and water but maldistribution and overindulgence. Through evolutionary deprivation, our bodies have learnt to do with ten morsels less, but we still have to evolve the physiology to manage a single morsel more. And that pampers much of the science of gastroenterology, obesity and the consequences thereof.
Ethics is essentially a solo journey, self-willed, voluntary, joyful and pursued entirely in enlightened self-interest. You do not want your reasoning, compassionate, unselfish and uncompromising right brain to pull you up in the dead of night or in solitude. Pasteur (17) aphorised that chance favours a prepared mind. Ethics emanates from an evolved mind, an entity, alas, fast withering. But when genuinely pursued, Ethics tries handling inner conflicts scientifically and spiritually. It is scientific on the basis of the right and left brain dichotomy; and spiritual from Chandogya Upanisad’s Tat Twam Asi [That art thou]. The patient is no one but your own alter self, obliged by heredity (or herd-ity) to bear the cross on your behalf as most diseases are primarily causeless and secondarily herdistic. Acute lymphocytic leukaemia (ALL), for example, has the fixed incidence of 1 in 33,000 year after year, generation after generation, race after race and country after country (18).
We do not wish to run down the current ethicists’ movement, which must continue. However, until such time as our educational system is truly humanised, the bankrupt right brain of the average medico will have no chance or capacity to question the deeds and misdeeds of the left brain. The few who dare to listen to the silent whisper (“the voice from within”, also called God or Spirit) of ethics are assured a soft pillow, a clear conscience, a regretless autumn of life.
Ethics at a mass level is too thoroughly, incorrigibly relativistic to assume a “the.. then” verity. In a way, it is mob rule as the sheer momentum of numbers outweighs the nuances and niceties of thought and fairness. The following is a case in point:
In 1933, the German government enacted one of the most comprehensive animal protection legislations in the world, the first in a series of laws to protect animals. “In the moral hierarchies born and bred in Nazi minds, there was no conflict between care for animals and genocide of Jews, since, in the Nazi reading, Jews were subhuman beings, lower than most animal species, comparable to vermin.” as Brinda Karat writes (19). How the exalted nation of Goethe, Wagner and Max Mueller could fall prey to the machinations of a maniac will remain a historic riddle. But at that time, each Jew exterminated ethically meant a ‘vermin’ squashed. The absence of conflict left no opportunity for the right brain to question the left, and that caused genocide on an epic scale.
Much the same dynamics could account for the massive erosion of conscience that ought to have plagued modern medicine, but has manifestly failed to do so. Nobel laureate Burnet concluded his brilliant Genes, dreams and realities (20) with despair: “The great pharmaceutical houses of the midtwentieth century may come to feature in history as examples both of the productivity of science applied to industry and the evil inherent in the technological momentum of a competitive industrial society.” Add to that a recent Selling sickness: how the world’s biggest pharmaceutical companies are turning us all into patients (21) and you only shudder at the fall. Today, textbooks, medical journals, conferences and workshops are in one way or another promoted by industrial might. It has the semblance of organisational décor and scientific probity. It is a mass movement, wherein the vital, ethical conflict, a strictly personal journey has poor weightage. An average medical mindset must change to usher in an ethical renaissance, much desired in medical practice.
It is high time we accepted honest therapeutic bankruptcy, as urged by Asher (22, 23), rather than indulging in ostentatious therapeutic nonsense, and cultivated healthy skepticism at every stage of medical practice. It is neither worth ignoring heresy in the pursuit of science, nor doing things merely to conform for fear of being left out. An understanding of this should become integral to medical weltanschauung. Only then would there be a healthy dialectic between the right brain and the left brain, the very heart of that difficult but lofty exercise called ethics.
Among the first mentions of this dilemma is Duryodhan’s lament in the Mahabharata: “Janami dharmam, na ca me pravrut, Janami adharmam na ca me nivrut (I know what I should do, but I cannot. I know what I should not, but I cannot withdraw from doing it).” (Prapanna Gita, 57-8) Many a conscientious medico, beset by social, financial and peer pressures, faces such a dilemma and ends up compromising on ethics. That is the reality.
A moot question that would plague every ethicist is whether ethics was violated in the Nazi concentration camps, in the Stalinist Gulags, in Rwanda Burundi, in Guantanamo Bay, in the Talibanistic jehadists stoning an adulteress to death, and in one genocide after another at our own doorsteps. Eusemantics – the right connotation of a word – demands that the term “ethics” be not invoked in any of the foregoing, since the perpetrators of the crimes were fully convinced of the righteousness of their actions, and did not suffer from any prick of conscience or did not question themselves, and hence, there was no dilemma. What they did was inhuman, indecent, cruel, immoral and unprofessional, but ethics had no role to play.
Is ethics at stake when a squiggle of the ECG needle lands an unsuspecting person into the whirlpool of cardiology or when a marginal rise in PSA in an asymptomatic person becomes the cause of a radical cystoprostatectomy (24)? Such dilemmas do bother some evolved medical minds day in and day out. Alas, the medical community in general is carried away by the mentality of doing. Ethics has no snowball’s chance in hell until the Jungian Community unconscious (25) decides to evolve for the better. In the modern progressive pervasiveness of I-me-mine, ethics must get short shrift. Poignantly, ethics begins with one’s own self and there it ends. Tragically, that began in the Mahabharata, with Duryodhan and rules the roost even today.
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