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Tuesday, June 10, 2008

Vesak Reflection on the Medical Profession

Vesak Reflection on the Medical Profession

‘Physicians’ as the very term implies deal with the body, which is subject to sickness, decay and death. As such physicians seem to be engaged in a Sisyphean task – an absurd, but for many lucrative, preoccupation devoted to propping up what Shakespeare called "this muddy vesture of decay". But if we shed the devaluation of the body on the basis of an assumed dichotomy of body and soul or the body and a rebirthing identity consciousness in mainstream Buddhism, we will have an exhilarating perspective on human existence. It helps us to cultivate a holistic view of the human person as a totality of vital processes or synergies. Whatever our religion, ethnicity or social status all human beings are subjected to the paradoxical character of the human condition. We must all die. What ethics has the science of medicine to teach us?

In Genealogy of Morals German philosopher Friedrich Nietzsche inquired into the historical origins of our moral concepts of ‘good’ and ‘evil’. Nietzsche’ writings are remarkable for the absence of footnotes. But there is one rare footnote in Genealogy of Morals..In it he questions the value of rational or intellectual philosophical constructs of ethical imperatives and speaks of the need "to reconfigure the relationship between philosophy and physiology and medicine". All our moral tablets of "dont’s", he adds, "wait upon a critique on the part of medicine". His meaning is clear; the critique on the part of medicine will make us ‘physio-logical’.

This means that every physician critically reflecting on the object of his profession could become the noblest of moral philosophers. This is because a physician in his surgery must keep his mind well earthed to tangible facts not fancies.

Physicians and health-carers are situated at the cutting edge of life and death and are everyday and night experiencing anicca and anatta. Therefore they, more than any other professional, including religious professionals, are in a privileged position to grasp the finiteness, the fragility and the perishability of human life. This is what makes life precious and sacred, not because it is an earnest of another more sublime life but because it is ephemeral and fraught with fragility. To live for another life, as Nietzsche pointed out, is to devalue this life on behalf of another. Physicians should be in the forefront of those who stand up for this life and speak up on issues which diminish and destroy life through war, reckless road use, unhygienic social conditions and medical malpractices because they are confronted with the tragic victims of these atrocities day in and day out.

Physicians follow the life process from the moment of conception to death. From the womb to the tomb; they follow the process of growth, the occurrence of illnesses, onset of the process of decay and physical infirmity and the final breakdown we call death. The physician perhaps more than any other professional is an intimate and daily witness of the ravages of disease and decay. They smell the stench of putrefying flesh while life still lingers, they see the way beauty withers, strength fades and how life ceases. This is also really his/her condition. The physician more than any other can see the relativity of things we cling to, pride of caste, family or class, social status and wealth. The physician has by his/her very profession the possibility of becoming a sage and a saint. In fact one of the pledges undertaken by the Hippocratic Oath is, "With purity and with holiness I will pass my life and practice my Art". If life is sacred, a physician treating a sick person is standing on holy ground.

It is customary to refer to people who come to be ministered by physicians as ‘patients’ A ‘patient’ is one who suffers illness and is a passive object subjected to the supervision and judgement of physicians – who are regarded as the competent speakers on the condition of the suffering ’other’. This perception of the doctor ‘patient’ relationship is reinforced by the ideological paradigm of Western medicine, which is the dominant form of medical practice in Sri Lanka. Western medicine is very strongly influenced by Cartesian and Newtonian asumptions of the mind as the sovereign subject (res cogitans – thinking substance) of thought and external reality as the object of thought and action (res extensa – material substance)

The body of the ‘patient’ is seen as ‘the other’ – the passive object of a physician’s invasive intervention. Physicians tend to forget that the seriously ill ‘object’ is a human person of flesh and blood in an acute state of distress – or dukkha – that he/she has equally distressed loved one’s like the physician and his/her similarly afflicted loved ones.

The Newtonian- Cartesian model of the world on which Western medicine developed has been superseded at the sub atomic level by quantum physics. Professor Carl von Weizsacker, German atomic physicist and philosopher, was interviewed in a Dutch TV programme on the challenge posed by the New Physics to religion and philosophy. The New Physics, the professor commented, calls for a new understanding of our world and a new ethical attitude to life and the world we live in. I quote from the transcript:

Consider the implications of quantum theory. In quantum theory we are describing the behaviour of stars and atoms and produce tables and figures as if we are spectators. But at the same time we realize, and we are reminded so profoundly of that old truth already understood by the Buddha that we are in fact telling our own story. Our own bodies consist of atoms; our own lives are part of that nature we are analyzing. We cannot separate it. We cannot speak of nature as if we did not belong to it. That is more or less the message of quantum theory. Now look at all the immense number of beings who are born, who live and die, who suffer because all life is suffering according to Buddha. But you cannot speak of this truth as something outside yourself, you yourself are born and you will die and you are going through a life of suffering because you build your life on false expectations which are frustrated, And in this situation you cannot distinguish between the onlooker - the one who looks and the one who is looked. You are one and the same you are in both roles at the same time.

It must become evident to mindful physicians that they are in the patient-healer roles at the same time. The microbes, the viruses, the bacteria in the patient, may be in the doctor himself. The blood pressure, the blood and urine samples studied are no different to what are measured in physician’s own body. The carcinoma, the weakened heart muscle or affected kidney or liver is no different to potential ailments in the organisms of physicians..Physicians heal bodies but do not have extra corporeal immunity.

Instead of the ‘object-other’, suffering patients who passively ‘suffer’ the all powerful gaze and determinations of physicians should evoke anukampa and karuna because the patient’s story of his-her ailment is also the physicians story. The patient is morphologically and physiologically no different to the physician. The form is the same, the heart is the same, the lungs ,the digestive processes, the genitals, the reproductive act, – conception and the birth processes are the same as that of the physician and his/her spouse, their children and parents. The orifices of the body and what ‘enters’ and ‘exits’ are similar. The difference of para /apara – ‘other’ and ‘not other’ should dissolve and with it the Buddha’s norm should come to mind "In protecting myself I protect others. In protecting others I protect myself".

Physicans and physiologists can come to a realisation of the fundamental equality of all humans beings, better than any bookish professor of law. The birth process is the same even if it takes place in the luxury of an air-conditioned delivery room with the best of gynecologists in attendance or in a wretched refugee camp. The little new born baby of affluent parents is as much a human as the child of impoverished parents. A virus can afflict the rich as well as the poor, even though the poor are more prone to sickness because of their weak physical condition as well as unhygienic environments.

We need body wisdom. It is the head which attaches ethnic labels and speaks of Sinhala, Tamil or Muslim. The profane stomach is innocent of such discrimination. The concepts of the womb are far less discriminating than the ‘concepts’ of the head. The womb can take the seed of a man of any race, caste or ethnicity and deliver a human child. What divides us is not our physiology but the conceits in our heads. If the doctor is not an ethnocentric or a class conscious prig, he must know that there is no such thing as a distinctive Sinhala, Tamil or Muslim features on the human body. "Not in the head the mouth, the eyes, the ears, the breast, etc., and not even in the genitals, which could divide humans into different species", as the Buddha pointed out in the Vasettha Sutra. If there were, there could be no universally effective medicine or surgery. The same course of medicine prescribed will heal irrespective of whether a physician is a Sinhala Tamil or Muslim and the patient Sinhala, Tamil, or Muslim. This is not some abstruse theory. It is happening everyday in real life in every clinic in every hospital. When a blood transfusion is needed only a bigot will ask who whether the patient and donor is Sinhala, Tamil or Muslim, There are no such blood types. We strip to be examined or are stripped for a major operation. The white cassock or the saffron robe, the skull cap and the pottu and burkah are of no consequence. We ‘dress ourselves up’ to demarcate differences. Naked and under the skin we are the same. Every doctor knows this.

Perhaps the best place to start a movement for radical democracy is not the temple or the parliament, but the hospital ward and the clinic. But this is where doctors and health workers hold poor patients to ransom by going on strike at the drop of a medical cap. Sickness does not discriminate. Therapists often do, though their very profession should compel democracy – the democracy of the body – not the proud sectarian ‘spirit’. Physicians must be in the forefront of those who are struggling to defend the sanctity of life and the right to the fullness of life.

Given this inexorable subjection to a common condition, the attitude of haughty and uncaring physicians and of uncaring health workers is incomprehensible. Doctors infected by the curse of commercialism seem to think that a ‘bill of health’ depends on the size of a purse. It is this cupidity and callousness which is paradoxical because: Each day doctors see fellow humans die, yet, many live and behave like immortal gods!

All life is passing passage. What nobler vocation can there be than to be called to ease the suffering of one's fellow human beings and help them live in good health and in wholesome and secure conditions? What greater joy can there be than this? The lure of pecuniary benefits and the luxuries they bring can hardly compare with the satisfaction that comes from serving one's suffering fellows - especially the poor and the powerless. Physicians have the potential to become noble men and women whose outlook on life is inspired by the compassionate prayer: sakale sathveyan niduk vethwa; sakala sathavyan nirogi vethw;, sakala sathavyan suvapath vethwa – May all beings be free of sorrow, may all beings be free of disease, may all being be well..

(This is the text of a lecture on Buddhism and Medical Ethics delivered at the SLMA auditorium in 2003. A summary was published in the February 2008 Bulletin of the College of General Practitioners of
Sri Lanka.)

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