Supriya Subramani, Passive Patient Culture in India: Disrespect in Law and Medicine. Routledge; 2025. Pages:198, GBP £116.00 (hardback) ISBN 9780367655365
By paying attention to the less explored intersection of medicine and law, the book contributes to an already dense field of study, the social determinants of health. In her book, Supriya Subramani brings together legal cases, medicine, ethnographic vignettes and her own encounter with the medical system, to comment on the passive patient culture in Indian medical discourse. Her analysis shows how social inequalities seep into healthcare and law, which by using a culture of disrespect and humiliation renders patients passive. The book, at times, records the experiential realities of the author and her lifeworld in Kannada script, it is an experiment that academics should carry out more often!
The Introduction, following from a useful preface, brings out the author’s own position in the social hierarchy that not only fulfils the anthropological expectation of reflexivity; but also helps the reader to clearly understand her standpoint and motivation. However, the introduction should have detailed the field site and method, as the location and timeline of the work remain elusive throughout the book. This makes it difficult to understand temporal, regional and social specificities, which are essential to understanding the context of marginalisation faced by Subramani’s informants. She does mention that details of her methods can be read in another of her papers (p 12), but this should have been explained in the book as well, for clarity.
The first chapter lays out the idea of an “active patient” as a basis to understand the “passive patient” in subsequent chapters. In this chapter, there is an unexplained gap in the literature review which moves abruptly from the concept of “sick role” introduced by a pioneer of medical sociology Talcott Parsons, to the contemporary medical sociology. The many shifts in medical anthropology, such as the challenge to the disease/illness binary and bringing the focus to “modern” medicine have been skipped (pp 28-29). Active and passive patienthood is the author’s own derivation, not an established or sufficiently explored category in medical anthropology. Hence, this portion should have been adequately developed in relation to several established conceptual categories within medical anthropology, to make the construction of the category of an “active patient” (and subsequently that of a “passive patient”) more comprehensible. In this chapter, the author continuously conflates medical anthropology with medicine. More elaboration was needed to keep medicine and anthropological analysis of it distinguishable from each other. It is also unclear what the author means by a “situated patient” (p 33), mentioned towards the end of the chapter, and if is it the same as “active patient”.
Chapter 2 turns its attention to the legal apparatus that regulates medical practice in India and the claim that the laws in India regulating medical institutions continue to carry their colonial heritage. Subramani asserts that while such laws have undergone many changes in the United Kingdom (UK) and the United States (US) to acknowledge the agency of the patient, India continues to cling to its outdated laws. The author may not have intended this, but the chapter gives a sense that everything has improved in US and UK in comparison to India. In fact, this is echoed through the book that the “passive patient” is an India specific phenomenon. This is a big assumption, since legal changes may not always translate into on-the-ground changes in medical practice. A review of changes only within the domain of law is insufficient to draw this inference. The chapter focuses primarily on the judgment in one medico-legal case, Samira Kohli vs. Dr Prabha Manchanda, to understand the passive patient culture. In this case, an unmarried 44-year-old woman Samira Kohli, complained of heavy menstrual flow. Advised by Dr Prabha Manchanda, who treated her, she went for a laparoscopic test under general anaesthesia. While Samira was unconscious and undergoing evaluation, the doctor took her mother’s consent for a hysterectomy and performed it. About six months later, Samira Kohli brought a claim for compensation of Rs 25 lakhs with the National Consumer Disputes Redressal Commission, alleging that the doctor had treated her negligently and had conducted bilateral salpingo-oophorectomy and a hysterectomy without her permission. The case in question could have been analysed in more detail and been supported by other medico-legal instances. Lacking this, the culture of passivity is difficult to believe in, for two reasons. One, the analysis of just one case is insufficient to support the author’s argument, especially because the chapter does not tell us the impact this case has had on subsequent cases. Second, the doctor was fined by the Supreme Court, so it cannot be said that the legal system sided with the medical system in creating and sustaining the passive patient culture. Pointing out a few minor issues, the author should have explained some of the legal terms such as the “Bolam test” (p 46) and medical terms such as “laparotomy” (p 50) for readers. Another interesting aspect Subramani could have picked up from the case was the role of family in rendering patients passive. Here, it was the mother of the patient who gave permission for the procedure that the patient did not want (p 50). This could, however, be seen as potential that can be realised in later works.
Moving away from legal discourse, the next two chapters (3 and 4) investigate the category of “passive patients” in a medical setting by analysing Subramani’s field narratives in both government and private hospitals. As mentioned earlier, the problem of not specifying region, timeline and method becomes more apparent in these two chapters and the region can only be inferred through the vernacular language spoken by the author’s informants. While reflexivity is valued in ethnographic writing, in this case, due to the missing temporal context, it does not have the desired impact. The author’s account of her own encounters with the medical system (which in most cases did not seem to happen at the same time as her fieldwork) seems abrupt and confounds the timeline of the work further. In both the foregoing chapters, passivity and marginalisation have been merged, and while both may overlap, they are two different things. The former may lead to the latter, but they are not the same. Another issue that affects both the chapters is that several kinds of marginalisations, ranging from sexuality to religion, caste and class, have been clubbed (p 81, 82, 109, 110) and have been rushed through. This takes away the space to engage with any one of them deeply and consequently appears as tokenism. The fourth chapter towards the end discusses “the perfect patient” (p 122) which could have been the starting point of the book, since passivity is one of the characteristics medicine wants in an ideal/perfect patient. Also, it is perplexing that, while there are many narratives of doctors and patients talking to the author, there is hardly any instance of a dialogue or direct confrontation between them. This would have helped the reader to observe how passivity is constructed and how it is resisted by the patient.
The concluding chapter (chapter 5) puts things in perspective and looks critically at the earlier chapters. This provides a very helpful summary, makes recommendations for more ethical treatment of patients and reiterates its importance. Chapter 5 explores this through Ambedkar’s concept of gaurav (p 130), which is especially interesting. However, the ideas of self-respect, especially in the caste context and the medical construction of passivity run parallel to each other. Their interweaving would have given us a new framework to revisit a well-accepted fact of social vulnerabilities seeping into medical practice and would have been a unique contribution to the field of medical ethics.
Overall, a couple of critical points that can be made: first and foremost; words such as, “passivity”, “disrespect”, “self-respect” etc appear in and out of quotation marks arbitrarily. This makes it difficult to understand whether the author is quoting from someone else or if they are her own categories. Moreover, the book keeps merging the categories such as “disrespect” and “humiliation” with “passivity”. As suggested earlier, they can overlap, but they are not the same. While a marginalised group or person struggles to get access to the medical system, a patient rendered passive still receives some form of medical care. In the same manner, a patient from a privileged background with access to the best medical facilities can still be rendered passive due to the tendency of biomedicine to treat the human body as a machine. Being mindful of these distinctions would have made Subramani’s analysis more nuanced. The connection between “humiliation/disrespect” and “passivity” could have provided an interesting intersection between Ambedkar’s ideas and theories of medical anthropology, but needed more attention. Also, the author has repeatedly used bulk citations with little engagement with the works of the authors cited. Detailing the argument of at least some of those authors and critical engagement with their work would have situated this book better in the medico-legal intersection it is exploring. Lastly, Subramani reads the instances where a doctor expects patients to trust them over googled information (p 3, 117) as an act leading to a patient’s humiliation and denial of a patient’s agency. This comes across as an overreading, because it could easily be seen as a fair demand from the doctor to dispel unreliable information from dubious sources.
Despite these shortcomings, the book has explored an important intersection between medical anthropology, medical ethics and legal studies, and will be useful for scholars willing to take this further.
Authors: Shweta Rani (shweta.rani@apu.edu.in, https://orcid.org/0009-0009-3567-8085), Assistant Professor, Public Health, Azim Premji University, Bengaluru, INDIA.
Conflict of Interest: None Funding: None
To cite: Rani S. The good, the bad and the passive: Patienthood in India. Indian J Med Ethics. Published online first on August 8, 2025. DOI: 10.20529/IJME.2025.062
Submission received: April 22, 2025
Submission accepted: May 31, 2025
Manuscript Editor: Sanjay A Pai
Copyright and license
©Indian Journal of Medical Ethics 2025: Open Access and Distributed under the Creative Commons license (CC BY-NC-ND 4.0), which permits only noncommercial and non-modified sharing in any medium, provided the original author(s) and source are credited.