Sunday, January 11, 2009

Ethics at the Swami Vivekananda Hospital

I'm in Mysore, in the South Indian state of Karnataka, for eight days, at the Vivekananda Institute of Indian Studies. The Institute is part of a remarkable twenty five year old non-governmental organization - Swami Vivekananda Youth Movement (SVYM).

I visited for two days at the hospital the NGO runs in Saragur, a rural community forty miles southwest of Mysore. The visit provided a rich perspective on the ethics of health care and health organizations. I've organized my initial thoughts around two questions, both involving the concept of health care as a calling:

1. If health care is a calling, where does the call come from? Dr. R. Balasubramianiam ("Balu"), currently president of the NGO, led a group of medical students at Mysore Medical College who founded SVYM in 1984. Balu described how at 17 he was "ragged" so harshly by the senior students at the engineering college he had enrolled in that he decided not to go back. Since simply staying at home wasn't an option, to cover up the fact that he wasn't at school he started to spend the hours he would have been at the engineering college at an ashram, where he encountered the teachings of Swami Vivekananda (1863 - 1902) and was inspired by Vivekananda's vision of service to the rural poor and of making India an educated, healthy, harmonious society. Medicine, in the form of service to the rural poor, became his calling.

Balu's narration of his traumatic experience at the engineering college teaches one lesson about the origins of medical calling. It typically has strong personal roots. Virtually all of the physicians, nurses and other health care professionals who (a) I admire and (b) I know well enough to ask about their path to health care (c) cite meaningful personal origins of their calling. These vary tremendously, but have in common being intensely important to the individual.

Pictures of Swami Vivekananda and placards with his most quotable sayings are all around the hospital. When an associate of the NGO told me that he himself was an atheist I asked him "if Swami Vivekananda were here and heard you say that - what would he say?" The response was - "the Swami was an atheist himself - he thought that any god who allowed so much suffering didn't deserve to be worshipped. He taught that the religious spirit was shown in service, not in ritual practices."

Dr. Sridevi Seetharam, a physician deeply involved with medical ethics, explained that in Sanskrit terms, the gentleman I quoted in the previous paragraph was talking about the devotional path known as Karma Yoga - "selfless service to others in one's chosen profession or area of work." Vivekananda was Hindu by birth, but taught that all religions are in some sense "true." In addition to the personal origins of each person's calling to health care, the hospital's inspiration, Swami Vivekananda, and the ancient tradition of devotion through a Karma Yoga, which can be entirely non-sectarian and non-theistic, provides an external pillar for the calling.

In the U.S. people of faith can, if they choose, base their calling on their religious beliefs. But the kind of framework the doctrine of Karma Yoga provides, is not part of our secular ethos. The professionals I most admire act as if they were carrying out a devotional process, but if asked to explain the foundation that underlies their care giving, they're often at a loss to articulate it, or say something like "this may sound like a cliche but..."

2. How does calling manifest itself at the organizational level? My time at the Vivekananda Hospital was limited, but:

* The hospital and its outpatient clinic serve a rural population that includes tribal people who are only recently out of the forest. There is a huge social gap between many of the patients and the well educated professional staff. But the professionals evinced an interest in and warmth towards the people they serve that seemed more like love than technical "cultural competence." The physicians we spoke with evinced deep empathy with the patients. One manifestation of this empathy was creation of a strong role for "patient care managers" who come from the rural population and guide patients through their interaction with the care program in a side by side manner. Empathy is also manifested by providing free lodging for family members who cannot go back to their villages at night because there are no buses after 5:00 PM.

* Physicians were remarkably knowledgeable about traditional Ayurvedic treatment methods and Ayurvedic clinicians were part of the staff. Patients whose traditions and beliefs included Ayurveda had access to this approach in a way that was integrated with the allopathic services they received.

* A holistic view of health as involving more than medical relief of pathological states led the hospital staff to initiate a range of other activities including health and hygiene education in the villages, support for school improvement, and promotion of a clean water supply.

* Finally, and most remarkable from an American perspective, the hospital holds a twice a week non-sectarian prayer meeting attended by all of the staff and all of the patients. I was not present for a prayer meeting, and I do not see it as a format that would fit into a secular U.S. institution, but finding acceptable ways of recognizing the calling that all are participating in is a desirable path to follow.


eric said...

Quiet time for vespers at the Carney Hospital in Boston. The elevators that opened and closed themselves on every floor during the Sabbath at Maimonides Hospital in Brooklyn. The daily Mincha afternoon prayer service at Beth Israel Hospital in Manhattan. The healing garden at Union Hospital in Lynn, Mass. The chapel in any hospital (always empty). These are times and places of peace that remind us that there is something bigger going on here than "allopathic medicine."
Many of my patients remind me of my calling, though I have only a vague and embarrassed sense of it. They thank me and bless me; and where I work now, it's most consistently the devout Catholic Hispanic people who unabashedly tell me of the gifts that G-d gave me to help them. Healing seems more likely to happen when we get out of the box of "Western Medicine." Where I work now, at PACE, we mean to serve all of peoples' needs with a multi-disciplinary team in many different settings. But we must do it in a studied way to satisfy the CMS bureaucracy and get it funded and steer clear of religious bias. Karma Yoga may be the way to institutionally recognize calling and spirituality without disturbing America's confused legal attitude toward religion.

Jim Sabin said...

Hello Eric -

Thank you for your very moving comment. I know that hospitals have religious services for patients of different faiths. What struck me at Vivekananda Hospital was a prayer meeting (it's also interfaith - mainly Hindu, some Muslims, a few Christians, and non-observers) that all patients and staff participate in.

I love the vignettes from your practice. What your Catholic Hispanic patients say to you is a common part of Indian culture. There is a Hindi saying that doctors are Gods who have come to earth to do good.

Again, thank you for these thoughts. I hope other readers join in as well.



Jim Sabin said...

Hello Ideng -

Thank you for this comment. Perhaps you chose to post the comment in relation to this posting because "womb for hire" is indeed an ethical issue of global scale now. Some libertarians favor allowing people to choose to sell their bodies - whether via "womb for hire" or organ donation. For two reasons I don't share that position. First, empirically it has been shown that the financial benefit is typically much less than the folks who've sold parts of themselves expect. Second, apart from those empirical findings, I regard body selling as an exploitative and corrupting social process. There are much more acceptable ways of dealing with poverty.



ybr (alias ybrao a donkey) said...

Vivekananda was not an atheist. He sacrificed goats at his Belur Math. Shri Ramakrishna's wife Sarada Devi discouraged it. She started the practice of offering bananas to the Goddess Kali, at Belur Math.

Click to see: Vivekananda's Letters- analysis.

There does not seem to be unethical in hiring wombs, as long as there is no exploitation of poor and it does not become a business.

Jim Sabin said...

Dear TruthSeeker -

I don't know anything about Vivekananda sacrificing goats, but by chance I just read in "The World Is What It Is," the authorized biography of V.S. Naipaul, about his father's sacrifice of a goat. Seepersad Naipaul, a journalist in Trinidad, wrote critically about "amazing superstitious practices" involving Kali. Kali followers predicted his death and demanded that he sacrifice a goat. Seepersad initially refused, but his wife prevailed upon him to do it!

With regard to surrogate parenting arrangements, I agree that this can be an altruistic gift from one to another. But it is becoming a substantial business, in India and elsewhere.