What Can Medical Ethics Contribute to Health and Health Care in India?

Yesterday I attended a conference at Harvard Business School - "The Indian Growth Story: Sleeping Elephant or Roaring Tiger?" I've been thinking about what medical ethics can contribute to health and health care in India since spending the month of January there, and I thought I might learn some useful things at the conference. (See as well this previous post on ethics teaching in India.)

I wasn't disappointed.

Before the conference started I had coffee with a group of young India men - some still in business school and some in their first jobs. When I told them about my interest in medical ethics, one asked "is it true that before a person (or a country) is established there is no time for ethics; when you are established then you can think about ethics?"

I told them we have to address ethical questions at every phase of personal and societal development, but the questions and expectations are different at each phase. My hunch was that early on the key job is creating an "ethics infrastructure" that will support ethically admirable health system in a later phase.

Several speakers made reference to "jugaad," a Hindi word meaning inventiveness, cleverness and ability to get things done in unorthodox ways. When I looked up the term, here's what I found:

It’s like putting two spoons of turmeric powder into your radiator if you spring a small leak. It works, it will seal the leak. In Punjab, I have seen villagers buying an agricultural water pump at government subsidised rates, cannibalising some other parts from here and there, and turning it into a vehicle. These are jugaads.

The excellent panels and plenary talks described a vibrant economy with lots of opportunity for any of the ambitious and entrepreneurial young people at the gathering who wanted to return to India. Jugaad was a common theme - finding distinctive Indian ways of addressing problems and promoting development.

As I understand it, jugaad is an attitude and set of skills that in themselves are morally neutral. In the U.S. Enron specialized in jugaad - ingenious but virulently unethical and often criminal innovations. But speakers like Dr. Pradip Kumar Sarmah, founder and executive director of the Rickshaw Bank, an enterprise that (a) makes microloans to rickshaw pullers to enable them to own their own rickshaws and (b) has supported design research to develop a new and more efficient rickshaw model showed how jugaad can promote social justice.

In U.S. medical ethics education we tend to focus on ethical nuances and conundrums - like whether a particular patient's refusal of treatment reflects decisional competence and should be respected or doesn't meet the criteria for informed choice. From what my Indian friends tell me I infer that a case like this would be premature - the teaching task would be conveying the concept of informed consent itself and working with the question of whether and why patient preferences should be respected.

My current best guess is that the key pieces of "ethics infrastructure" to focus on are (1) informed consent, (2) research ethics, especially the ethics of clinical trials, which is a booming industry in India, and (3) strengthening the expectation that health professionals must consider population health and the common good as well as their own immediate practices.

The "Beggar's Song" in "Threepenny Opera" told us that some basics must take precedence over ethical niceties - "First feed the face, and then talk right from wrong...for even saintly folk, can act like sinners, unless they've had their customary dinners!" This was behind the question I was asked at the beginning of the day, with the implication that a concern with ethics is an impediment to development.

But I think the ancient rabbis got it right when they taught "Without sustenance there is no Torah (ethics); but without Torah, there is no sustenance." With enough skill at jugaad, ethics and development can go hand in hand!