Friday, January 9, 2015
Living among the Pacific Coastal Natives of Klemtu, B.C.
Life on the Pacific Coast began
after six hours of travel from Vancouver on three different planes. The final
leg was aboard a harrowing and noisy 4-seat “Beaver” prop-plane built in the
60s which tilted with every gust but landed us safely on the choppy water of
the bay in Klemtu. As we approached the dock I was greeted by the magnificence
of the Big House jutting out on a small peninsula, the face of the wooden
building painted with enormous black and red animal-iconography and surrounded
by snow-topped trees and a dreamy mist. My wife Alexandra met me in a beat-up
white pickup truck and we brought my gear up to what would be our new home
right on the ocean. That night we were awoken abruptly by sirens and phone
calls informing us of a tsunami warning. There had been an earthquake close to
the more northerly islands of Haida Gwaii. We were evacuated to higher ground
and I unexpectedly had my first meeting with the community as we helped some of
the elderly walk the steps up to the community centre. A familiar routine,
people of all ages were friendly and energetic despite the late hour. It was
then that I met an adorable and deeply respected matriarch who was the oldest
Klemtu local, close to her 100th year. Seeing the heartwarming display of
mutual helpfulness and spontaneous storytelling of previous tsunami warnings, I immediately became enamoured with the people of Klemtu and their palpable sense of community.
Moving to a remote Native
reservation on the Pacific Coast came about by fortunate opportunity, and
living in Klemtu changed our lives forever. Through Health Canada, Alex had her
choice of working as a Community Health Nurse on a number of Canadian Native
reservations. She chose Klemtu based on its coastal location. Formerly called
“China Hat” because of the shape of a small parallel island nearby (now known
as Cone Island), Klemtu is only accessible by boat or float-plane. This meant
shipping our goods by barge and getting used to the realities of living
remotely such as having access to only one tiny Chinese food restaurant, and
the limited availability of fruit and vegetables at the single convenience
store and solitary grocery. The fishing village of around 400 community members
is located mid-coast on Swindle Island. Here, two Nations live together in
harmony, the Kitasoo of Tsimshian descent and the Xai’Xais who are Heiltsuk. A
testament to their co-operative relations, their shared ceremonial Long House
was built fairly recently and is truly remarkable inside and out. Made mostly
of cedar, the sights, smells and vibrations of the spacious and earthen-floored
building filled me with awe. Enormous Douglas Firs and celebrated carvers were
brought in for the main cross-beams and astounding floor-to-ceiling totems
representing the four main coastal clans: Blackfish, Eagle, Raven and
Wolf.
Being a coastal Native community,
fish are of course central to day-to-day life. Conversation revolves around the
seasonal appearances and catching success of spring herring, summer halibut and
fall salmon. Many work at the hatchery and the Marine Harvest fishery, and
families have shallow metal boats called ‘punts’ for private fishing. There
also is burgeoning eco-tourism through the Spirit Bear Lodge which provides
both employment for locals and boat-tours for international visitors looking to
experience the flora and fauna of the Great Bear Rainforest. As the lodge name
suggests, catching a glimpse of the elusive white bears that are held as sacred
by Coastal Natives is of particular interest. Last season there was an even
rarer sight of a Spirit Bear cub! Nominated by National Geographic as one of
the top locations for ecologically sensitive tourism, locals often joke that
unlike the tourists who often spend a great deal on their visits, they get to
see all of the what the area has to offer for free!
Living in one of the largest intact
temperate rainforests on the planet means milder temperatures, lush greenery
and an abundance of wildlife. It also ensures almost continuous precipitation.
On one rare sunny day, one fellow gave me a local opinion on Klemtu weather
when I asked how he was doing and he replied wistfully, “Terrible. It’s not
raining!” As with the seasonal monsoons in India, I got used to the rain and
its various forms. The wind through the channel that our housing backed onto,
separating Swindle and Cone Islands, made for exciting fog formations but also
rainfall in every possible direction, even horizontally! Quite untouched
despite an Indigenous presence for millenia, there are plentiful hiking opportunities.
Twenty minutes above the village and
surrounded by mountains is the pristine lake that provides the community with
their fresh water supply and offering a landscape which my mother-in-law
described as “the best church I have ever attended.” The lake feeds two
swimming-holes, one that is easy to reach and another that requires walking up
through a stream and climbing over fallen trees and huge boulders carpeted with
moss until one reaches a majestic forest nook seen by only a handful of humans.
The small but deep water-hole has been enjoyed by local children for
generations and is surrounded by ferns, huge trees and rock formations that beg
one to leap off! Some nature experiences of the region were a first for me,
such as spotting Orcas from one of the B.C. ferries, regular Bald Eagle
sightings and hearing the otherworldly guttural call of an Elephant Seal.
However, it was the proximity to whales that really took the cake. One day
while biking to the ferry-dock I spotted something dark breaching the ocean
surface about a half click away. For the next hour I had the privilege of
observing a Humpback regularly coming up for air and then diving to reveal both
pectoral fins and the tail fluke. The water from its blow-hole often sprayed
onto nearby trees, showing the steep drop of the rocky shoreline. Nary another
human in sight, this surreal event gave me a sense as to why these beings are
held in such esteem. This was reinforced on another occasion when I was taking
in the stars one night amidst a sky amazingly dark due to low light pollution.
I heard waves breaking on the shore of the channel. No boats had passed
recently and then, in the pitch darkness, I heard bursts of breathing from
multiple locations and realized that a pod of whales was swimming through the
channel. For hours they swam and breathed nearby, and my experience during that
time was indescribable save to say that it prompted something akin to a
meditative state.
Although the experience of nature in
Klemtu made for unforgettable memories, it is the people of Klemtu that changed
us forever. On my first visit to the hatchery, a worker launched into a series
of spine-chilling Sasquatch stories. A popular topic in Klemtu, to be sure,
local sightings have led many Bigfoot researchers to come to the area in search
of the creature over the years. One of the most enjoyable ways to regularly
socialize was the weekly indoor volleyball games, evenings full of laughter,
blaring dance and rock music and happy children. Thanks to our neighbours and friends we also partook of many
local foods, each with unique methods of preparation, such as seaweed, herring
eggs, clams, crabs, sea urchin, ooligan grease and of course: fish! The salmon
run is central to the Klemtu annual cycle and is marked by several stages.
First, the fish steadily head into the bay towards the rivers. Soon the fish
are jumping right out of the water, some suggest to stir their eggs, which
makes for a furious cacophony of leaping fish that I would watch for hours.
Next is the catching of fish in huge, but controlled, amounts and fish storage
preparation by filleting, jarring and smoking for winter. Lastly, there is the
extracting of eggs and sperm for hatching next season. We were taught by many
how to fillet, and a Grand Chief allowed us to observe the smoking of salmon on
planks around a fire. He joked that the spread-open salmon looked like small
pants, but then told us that it is important to not joke about fish because
such disrespect could cause them to not return. I grew up in a Jewish household
that adored smoked salmon (lox), but as an indispensable traditional food
source on the coast, salmon is taken to amazingly creative levels. My favourite
salmon dish, dried and salted strips called Gravlox and served with a dill-based
dip, was given to us by a friend and I was hooked. At home, I enjoyed outdoor
salmon grilling on cedar planks (that I chopped myself!) to get a smoky
flavour. As Alex was the primary caregiver for the entire community, and
gift-giving a way of life, she was often rewarded with seafood. I started
baking bread to reciprocate. Every couple of weeks I also had the opportunity
to cook lunch for the health centre staff, and several times I had the pleasure
of cooking with an enthusiastic young local. When a Cree motivational hip-hop
artist was to visit for the purpose of both performing and facilitating
self-empowerment sharing-circles with locals, I was asked to bring sound,
lights and smoke up from Vancouver. This was much to the delight of the
community, especially the children who zoomed around with zest. Many people had
neither gone very far out of the area nor seen live music of this sort, and
seeing the silhouette of a traditional community line-dance on the backdrop of
coloured smoke and lights pulsing to dance-music showed a breathtaking
incorporation of the modern with the traditional. These small gestures were
meant to thank the people for allowing me to live in their midst and have the
chance get to know them.
In Klemtu traditional spirituality
and organized religion run in parallel but not without mutual influence. We
received several invitations to participate in both ceremony and services. The
school is a hub of community activity and host to many events such as
Aboriginal Day and the Terry Fox fundraiser, but far and above the most
touching for me was a mini-potlach that was organized by the Klemtu
school-children. The giving feast was peppered with sacred dance and song by
the children in their clan-based regalia, as well as heartwarming speeches of
thanksgiving, and culminated in everyone creating a circular friendship dance.
I was also invited to a Christian service which was full of hymn-singing to
guitar accompaniment, fellowship, and deeply moving testimony. Many of those in
Klemtu identify as Christian and as such, multi-denominational missionary
visits are frequent and welcomed by the community. Fundraising for a new church
building is currently underway. As we became more integrated into this small
community, we were also advised to have an elder smoke our house for
purification purposes. The elder who kindly agreed had us procure Poison Root
and she smoked the space while asking in her mother-tongue for the spirits to
not disturb us, and reassured them that Alex was in Klemtu to care for the
community. Poison Root is used both ritually and as an analgesic, so to replace
that used for the house-smoking some friends took us out to the forest to dig
up more. We found more than enough to reimburse and also leave some at
entrances, which is meant to provide ongoing protection from spirit
interference.
The timing of this adventure was
perfect for me as my PhD classes were completed and preparing for my exams
off-site entirely possible. The hardest part of leaving Toronto was extracting
myself from the music scene, both with playing and running concerts, with which
I had been deeply invested in for 7 years. Ultimately, I wanted to support
Alex’s dream of remote nursing and I did my best to help her stay healthy in a
job that takes tremendous amounts of energy. Nurses came and went but being the
only full-time nurse with only biweekly physician support meant that Alex was
the primary caregiver for the entire community. Nursing was thus not
constrained to the weekly 9-5 but included being on-call nightly. In some
extremely moving gestures at a memorial before we left, Alex received many
gifts and accolades for her service to the community. A Chief gave me a hat
because, as he explained, “he takes care of Alex so that she can take care of
us.” In addition to studying and being “the nurse’s husband”, through my daily
informal interactions with the people of this small community, including Band
Council members, Chiefs and Grand Chiefs, I increasingly saw the
anthropological potential of my being in Klemtu. I started to develop an
ethnomedical research project aiming to investigate the influence of organized
religion and traditional spirituality on health care decision-making among the
locals. While considering the potential project, I was acutely aware of the
historical harms and the continued systematic violence to Canadian Aboriginals.
The Tri-Council research policies in relation to Aboriginal Studies involving
human subjects are understandably rigorous and include such requirements as
ensuring the input and direction of Knowledge Holders, as well as leaving data
ownership and publishing decisions entirely in Native hands. As such, it was
only after months of discussions with key local leaders, proposal writing, and
U of T ethics approval that I approached the Klemtu Research Stewardship Board
to broach the subject of a research collaboration. There was enthusiasm for the
project and permission was granted with great anticipation particularly for
archival data of the unique perspectives of elders. There was also the
suggestion that food be included as an added topic of importance given the
intimate relationship in Klemtu between health and traditional food sources.
Klemtu spearheads a tremendous amount of research on resources in their
territory, research indispensable to such concerns as bear conservancy,
fish-stock maintenance and protection against industrial interference such as
with the Enbridge pipeline project. A grave concern that pervades daily
discussions, the Pacific Coastal Nations are vocally against the pipeline
proposal. It would result in tankers navigating difficult waters and the
statistical inevitability of a disaster that would devastate the ecosystem of
the entire coast.
During our stay, a monumental
provincial shift was taking place with the delivery of Aboriginal Health Care
moving from federal to Native control. This has been long in the making,
perhaps even since the initial colonial interference in Native health and
healing. For us the shift meant an end to the Health Canada contract and,
unfortunately, caused our relocation to come to a rather abrupt end. We
immediately started planning our return for shorter stays in the future. I am
deeply grateful to the Kitasoo/Xai’Xais peoples for so warmly embracing us and
allowing us to live together on their land and waters, and inviting us into
their lives for the year Alex was there and the half-year I was able to be
there. We miss the people of Klemtu terribly and often are asked by our dear
friends when we will be “coming home.” Our plan is to coordinate our return
with the naming ceremony of one of our close friends who will be inheriting his
late father’s title as Chief. We’ll stay for some time while Alex nurses and I
continue the research project where we left off. We may be Ontarians, but our
hearts belong to B.C. and the people of Klemtu.
Monday, August 4, 2014
Mention in "Wild Geese: Buddhism in Canada" 2010 book published by McGill-Queen's Press
Sean Hillman is mentioned in the 2010 Gill-Queen's Press book Wild Geese: Buddhism in Canada, edited by John S. Harding, Victor Sogen Hori and Alexander Soucy. Interestingly, a year after the book was published, Sean acted as a Teaching Assistant for the author of the chapter in which he appears, “Buddhism After the Seventies” by Prof. Henry Shiu. They soon realized they had a common academic link in Prof. Leonard Priestly, an erudite scholar of Indian Buddhism, Chinese religions and Sanskrit and Chinese languages. Prof. Priestly was Prof. Shiu's doctoral supervisor and also Sean's first professor in Asian Religious Studies at the University of Toronto (Introduction to Buddhism, Introduction to Taoism, Indian Buddhism) in the early 90s. In the chapter, Prof. Shiu refers to Sean's activities in caring for the dying as well as a talk on palliative care he gave in 2006 when he was still a fully ordained Buddhist monk.
From the publisher's page for the book:
"Sociology: Canadian. History: Canadian, Religious Studies.
The most comprehensive study of Buddhism in Canada to date. Buddhism has been practiced in Canada for more than a century and in recent years has grown dramatically. Immigrant communities construct temples in Canada's urban centres, the Dalai Lama is one of the world's most recognizable figures, and Buddhist ideas and practices such as meditation, vegetarianism, and non-violence are increasingly a part of mainstream culture. More native-born Canadians are turning to Buddhism now than ever before. The most comprehensive study of Buddhism in Canada to date, Wild Geese offers a history of the religion's evolution in Canada, surveys the diverse communities and beliefs of Canadian Buddhists, and presents biographies of Buddhist leaders. The essays cover a broad range of topics, including Chinese, Tibetan, Lao, Japanese, Korean, and Vietnamese Buddhisms, critical reflections on Buddhism in the West, census data on the growth of the religion, and analysis of the global context for the growth of Buddhism in Canada. Presenting a sweeping portrait of a crucial part of the multicultural mosaic, Wild Geese is essential reading for anyone interested in religious life in Canada."
From the publisher's page for the book:
"Sociology: Canadian. History: Canadian, Religious Studies.
The most comprehensive study of Buddhism in Canada to date. Buddhism has been practiced in Canada for more than a century and in recent years has grown dramatically. Immigrant communities construct temples in Canada's urban centres, the Dalai Lama is one of the world's most recognizable figures, and Buddhist ideas and practices such as meditation, vegetarianism, and non-violence are increasingly a part of mainstream culture. More native-born Canadians are turning to Buddhism now than ever before. The most comprehensive study of Buddhism in Canada to date, Wild Geese offers a history of the religion's evolution in Canada, surveys the diverse communities and beliefs of Canadian Buddhists, and presents biographies of Buddhist leaders. The essays cover a broad range of topics, including Chinese, Tibetan, Lao, Japanese, Korean, and Vietnamese Buddhisms, critical reflections on Buddhism in the West, census data on the growth of the religion, and analysis of the global context for the growth of Buddhism in Canada. Presenting a sweeping portrait of a crucial part of the multicultural mosaic, Wild Geese is essential reading for anyone interested in religious life in Canada."
"Bhikshu Tenzin Sherab, born Sean Hillman, a Canadian Buddhist monk ordained in the Tibetan tradition, is also a nursing assistant involved in hospice service at a hospital in downtown Toronto (Shiu 2010: 99)."
"An educational conference on palliative care, entitled 'Caring for the Dying in a Multicultural Society: Ethical, Religious, Social and Cultural Perspectives,' took place in Toronto in April 2006, with Tenzin Sherab addressing the audience from a Buddhist perspective (Shiu 2010: 109)."
Shiu, Henry C.H. “Buddhism After the Seventies.” Wild Geese: Buddhism in Canada. Ed. John S. Harding et al. McGill-Queen's Press, 2010: 84-110.
"An educational conference on palliative care, entitled 'Caring for the Dying in a Multicultural Society: Ethical, Religious, Social and Cultural Perspectives,' took place in Toronto in April 2006, with Tenzin Sherab addressing the audience from a Buddhist perspective (Shiu 2010: 109)."
Shiu, Henry C.H. “Buddhism After the Seventies.” Wild Geese: Buddhism in Canada. Ed. John S. Harding et al. McGill-Queen's Press, 2010: 84-110.
Thursday, April 3, 2014
Health Care Decision-making in India
Sean Hillman, PhD student (Department for the Study of Religion, University of Toronto)
2013
Introduction
The concern of my overall doctoral research project is the influence of religion on adherents’ views of health and disease/illness in contemporary India and how this affects health care decisionmaking, particularly those at the end-of-life. To begin to understand the processes of health care decision-making in India, both in theory and practice and with particular concern for the players involved and the respective power they wield, I will delve into two textual genres from within law and anthropology, and subdivide the paper accordingly. They are: (1) judicial proceedings, and (2) anthropological surveys.
Judicial Proceedings
Jyotica Pragya Kumar’s dissertation Informed Consent in Judicial Discourse: India and Canada 1996-2003 for a University of Toronto Sociology doctorate contains a chapter on “A Profile of the Doctor-Patient Relationship in India.” This section proved indispensable in beginning the process of discovering court proceedings that address the issue of health care decision-making in contemporary India. Kumar first establishes the nature of the doctor-patient relationship in India:
The relationship between the doctor and the patient is not a ‘contract of service’ - an expression which implies a master-servant relationship and involves an obligation to obey orders in the work to be performed and as its mode and manner of performance. A patient, on the other hand, cannot command the doctor to administer to him or her particular treatment if the same is not prescribed or approved by the latter. The relationship between the two is, at most, a ‘contract for service’, which signifies a contract whereby the doctor undertakes to render professional services, in the performance of which he is not subject to detailed direction and control by the patient. The doctor exercises professional judgment and uses his or her own knowledge and discretion quite independent of the patient (footnote 3: See Indian Medical Association v. V.P. Shanta and others, AIR 1998 Supreme Court 550 at 561 (para. 41) (26).
Within the context of this relationship, “a doctor’s professional decision-making functions are broadly divided into three phases: ‘diagnosis, advice and treatment’ (f16: Per Lord Bridge in Sidaway v. Bethlam Royal Hospital Governors and others, (1985) 1 All E.R. 643 (H.L.) at 660 c.)” (29). Although Kumar determines that “out of these, the functions relating to ‘diagnosis’ and ‘treatment’ have been clearly held to fall within the ambit of professional decision-making” (29), she distinguishes them from the phase of ‘advice’:
…the term ‘advice’ is used in a wider sense to cover “information as to risk and options of alternative treatment.”… Two lines of thinking, representing two different approaches, are in vogue. One view is that the determination of the doctor’s legal duty to advise is a matter of medical judgment, the professional decision-making. The other view is that this duty to advise cannot be left to the doctor’s judgment, because it is essentially a matter that impinges upon the right of a patient to ‘personal decision-making.’ India, following the English courts, has adopted the former approach, which gives primacy to the doctor’s decision-making for the patient; whereas…the latter approach…emphasizes the autonomy of the patient’s eventual decision-making… Since India has hitherto adopted the British approach, it would be in order to take note of the decision of the House of Lords in Sidaway, which gives primacy to the decision of the doctor over the patient (31-32).
With both the interpretation of “contract for service” in the Indian Medical Association case and “advice” in Sidaway lending judiciary strength to the physician’s independence in decision-making in India, we see not only the autonomy of the patient endangered but both collaborative and heteronomous decisionmaking models rendered difficult or impossible. I construe “collaborative decision-making” as that involving at least two parties, and “heteronomous decision-making” as that involving at least three parties having particular roles. My definition and usage of these terms will be explained in more detail in our case study later. From the Supreme Court ruling in relation to another case, Achutrao Haribhau Khodwa and others v. State of Maharashtra and others (AIR 1996 SC 2377), it is made “evident that the ambit of the decision-making authority of the doctor in India is very wide and almost unrestricted. This is amply clear as a matter of law as well as practice that if, in a given case, more than one course of treatment may be available for treating a patient, it is the doctor, and not the patient, who decides which course is to be adopted” (37). With one qualifier rendered useless by context specificity, Kumar concludes that the predominant decision-making model leaves all of the power in the hands of the physician:
The only restraint is that he ‘must bring to his task a reasonable degree of skill and knowledge and must exercise a reasonable degree of care.’ For meeting the standard of ‘reasonableness’, what is expected of the doctor is neither ‘the very highest’ nor a ‘very low degree’ of care and competence, judged in the light of the particular circumstances of each case. This is ‘what the law requires’ in India, and this is the law, which has been again affirmed by the Supreme Court recently in Vinitha Ashok v. Lakshmi Hospital… We may describe this approach as ‘doctor-centric’ (37-38).
In addition to the unclear nature of ‘reasonableness,’ the principle of ‘best interest’ is mobilized to protect doctors during litigation. During a 1991 appeal in the case of M.K. Verghese v. San Joc Hospital (39), the court’s observation “reflects the predominance of the ‘doctor-centric’ approach” since “‘informed consent’ in India just means informing the patient what the attending doctor did or intended to do in the best interest of the patient without the necessity of having any return response from him or her (patient)” (43). A trend crippling to both autonomy and collaboration in decision-making, Kumar’s “analysis of the Indian cases reveals that, hitherto, the patient’s autonomy to decide for himself or herself is completely absorbed into the decision-making authority of the doctor” (44). She notes, however, that the trend is shifting:
…the smooth functioning of doctor-patient relationship seems to be premised on the unwritten understanding of patient’s complete faith, trust and confidence in the capability of the doctor. However, cases have started coming to the courts, increasing in number, showing a questioning of doctor’s authority, which until relatively recently, was beyond reproach… [With] increasing awareness of the people at large generally, and the patient population in particular about their rights…[, there is a new] trend of asserting rights against doctors, and thereby changing their paternalistic attitude (46-47). Another judicial move found in Chandra Shukla v Union of India (AIR 1987 ACJ 628) and mentioned by Omprakash V.Nandimath of the National Law School of India University in Bangalore, has hindered the paternalism of Indian doctors:
For the fist time in India, the court ruled that however broad consent might be for diagnostic procedure, it can not be used for therapeutic surgery. Furthermore, the court observed that "where the consent by the patient is for a particular operative surgery it can't be treated as consent for an unauthorized additional procedure involving removal of an organ only on the ground that it is beneficial to the patient or is likely to prevent some danger developing in the future, where there is no imminent danger to the life or health of the patient". This proposition puts fetter upon the role of a "paternal doctor" in the Indian scenario. (344)
In addition to Kumar’s assessment that such “development signals that the society in India has also started moving gradually in the direction of individual autonomy” (49), I hold that it also paves the way for collaborative decision-making models to make their way into Indian hospitals.
Despite a discussion on the increase of malpractice suits against physicians, strangely Kumar does not give any examples of courts ruling in favour of patient complainants in malpractice suits against physicians, which supports her argument that although moving towards patient autonomy, consent and decision-making remains doctor-centric. However, Nandimath cites Maneka Gandhi v Union of India (AIR 1978 SC 597) in which the courts ruled in the patient’s favour. This case is very similar to many cited by Kumar where the scenario has a surgeon opening up a patient to deal with one organ in a particular way and removes another organ without consent because it is found to be unhealthy. The crucial difference in this case is the removal of the unhealthy organ led to another organ being compromised. Nandimath also attempts to broach the topic of the processes of ranking of Substitute Decision-makers (SDM) but without any evidence since judicial or institutional regulations that might control the practice are absent: “Regarding proxy consent, when the patient is unable to give consent himself, there are no clear regulations or principles developed in India. If such a situation exists, the medical practitioner may proceed with treatment by taking the consent of any relative of the patient or even an attendant” (345, emphasis added). Without a legal ranking of SDMs the danger that I can see is that relatives that are close by way of proximity rather than by relation might be treated as SDMs. In ranking SDMs, Canada’s Health Care Consent Act favours spouses, partners and relatives in descending order with regard to decisionmaking. ‘Spouses’ are defined by marriage, co-habitation, or having a child together (c.2, Sched. A, s. 59.7), whereas ‘partners’ are defined as those with a “close personal relationship that is of primary importance in both persons’ lives” (c.18, Sched. A, s. 10) and would of course accommodate same-sex couples. These relationships are given prominence by the legislation. Next, ‘relatives’ are defined by “blood, marriage or adoption” (c.2, Sched. A, s. 20.10). In theory, the logic behind privileging close kin as defined by the patient is to get as close to possible to the patient’s autonomous wishes in determining courses of action that are in their best interests. Despite such legislation, in practice I have observed too many times to count that those close to the incompetent patient in proximity are the main source accessed by health care teams during difficult decisions. Igor Pietkiewicz, a Polish medical anthropologist in Tibetan Studies, notes that “[h]ierarchy and subordination within technomedicine is expressed in the relationship between individual and institution, in which hospital routines are subject to the convenience of the medical staff, not the patient” (Pietkiewicz 39). This is often the case with regard to decisionmaking in Toronto hospitals. It is simply easier to make decisions with people physically present regardless of where they fall in the hierarchy of suitable SDMs. This practice of accessing proximal patient relations over those with degrees of closeness, which I have observed in many hospital contexts but particularly within critical care areas such as Emergency and Intensive Care where lives usually hang in the balance, is exacerbated by time-constraints, degree of seriousness of the patient condition and language barriers. Nandimath points to a conflation of spouses, partners and relatives by blood, marriage or adoption with the term “relatives” in an Indian health care context.
Anthropological Surveys
Mining the Journal of the Anthropological Survey of India for articles related to health and decision-making yielded some interesting data spanning two decades. Articles of interest cluster in the early eighties and around the cusp of the new millennium, and I will address them chronologically. I have left spelling and grammatical errors from the original articles intact and have not indicated such mistakes save for one glaring mispelling.
In Asha Datta’s 1982 article “A Study of Diagnostic Patterns of Mental Illness in Calcutta Hospitals and their Relation to Some Social Variables,” the investigator attempts to uncover the “belief about mental illness held by persons coming into contact with the ‘mentally ill’” since it “is of significance in proper diagnosis, prompt treatment and effective aftercare of the patients” (85). Informants were “the relatives of some of the out-patients” and “were approached to assess their belief about mental illness and their attitude towards their respective patients” (86). As was found in Nandimath with regard to the term ‘relatives’ in substitute decision-making, the various types of these relationships are not distinguished. The questionnaire results were subdivided into several models. Within the “Family model…There are many who…ascribe to the belief that the family is responsible for the illness and cure of mental patients” (93). The “Intrapersonal model” showed that some “agree that the patient is responsible for his own condition; and cure,” and in the “Social model…90% of [respondents] hold the society responsible for the treatment” (94). As shown above, the lack of symmetry in the presentation of results makes it difficult to say much other than most adhere to the ‘social model’ and people to a greater or lesser degree hold to the others. It is also not made clear what is meant by either ‘society’ or ‘responsibility.’ Does the former include private citizens, health care professionals and institutions as well as governmental bodies? Does the latter include both resources and decisions? Another statement not made entirely clear is the finding that “[t]he attitude of relatives of patients is benign,” but could mean that relatives do not begrudge the mentally ill family member for the burden their illness bears on them since “[t]he patient is viewed mostly as dependent” (95). This at least tells us that in 1982 Calcutta, decisions were more likely to be made by those other than the mentally ill patient themselves. We can surmise that competence would have much to do with this.
Bhowmik and Pal’s 1984 “Indigenous Health Practices Among the Nocte of Arunachal Pradesh” focuses on a group that “occupies the Central part of the Tirap District of Arunachal Pradesh numbering 24, 292 according to 1971 Census” (36). Regarding “Disease and treatment … Generally the professional expert among them is consulted in case of long suffering or any complication. The medicineman prescribes material of either plant or animal origin” (41). There is no mention of any negotiation around prescriptions so it might be safe to say that such decisions for traditional treatments are made by such healers for the patient. However, in the context of the “Impact of Modernization” the investigators found that “[i]n most of the injury cases, the Nocte like stitching which is done in the hospital” and that “[n]ow-a-days the Nocte prefer injection than oral medicines. The idea prevails that in injection entire medicine is accepted in body whereas in oral medicines some may go out of body through body secretions” (51). This indicates to me some degree of autonomy exerted among this group in relation to biomedical health care professionals as they seek out particular interventions, and accept certain treatments and refuse others.
In Kumari’s 1997 “Health Hazards among the Tribals and their Cultural Cognition for Modern Medical System: A Case Study of Rajendra Medical College and Hospital, Ranchi,” tribal use of hospital interventions is again investigated but this time in the second most populous city in the state of Jharkhand. One of the researcher’s main findings is significant to decision-making, but not surprising:
...in the hospital, there exists communication gap between the poor illiterate patients and specialists…. One of the important reasons why the tribals use folk modes of health care, because the patients and his relatives feel they can talk more freely to folk medicinemen than with modern physician. The interpersonal relationship between tribals and folk practitioners on one hand and the rural tribals and modern medical practitioner on the other hand are considerably different. Thus there exists a communication gap on emotional plane in the hospital between the patients and professionals.
On the contrary to the indigenous medical practices, western system of medicine is alien to the cultural pattern of the rural folk. Modern doctors fail to lounch [sic] their scientific advice in terms which fit on already existing cultural pattern creating gap on cultural plane. Thirdly, practitioners of modern medicine come from well to do families. By their education and training they tend to be sophisticated. This leave a gap between intellectual level of the practitioners and the illiterate patients. There is an enormous social distance between the two groups (83).
In this case, patients are disempowered in decision-making processes due to several factors: lack of familiarity with biomedicine; technical language usage by physicians; and social stratification. The article concludes with the recommendation that “[t]he health care system has therefore to be deprofessionalize…to provide better services to poor masses…” and among nine suggestions gives this: “Efforts should be made to fit the practice of medicine to the role that is appropriate to social system of the tribal people. Educated young tribals of both sexes should be recruited as health staff in health centres who will able to understand their own affairs promptly” (84). Although not elaborated upon, obstacles arising from gender relations is a notable concern.
Banerjee’s “Some Psycho-social Problems of Old Age among the Bengalis of Meghalaya” in 2000 “tries to highlight the role of Bengali aged people in the family in terms of decision-making processes” (69). It is unfortunate that health care decisions were not included in this survey. Regardless, it was found that:
It is generally believed that in changing life-style and increase in average longevity, the aged people in the present time are not enjoying the same respect and position as their predecessors used to enjoy in their days. With this view in mind we have examined in this section to what extent their opinions are being valued in family affairs like (i) financial matter, (ii) marriage of children, (iii) children’s education, iv) participation in social activities (77).
Although not done in the article, I extrapolated the results by combining all family affairs. There is a great discrepancy based on gender. For males, 37.7% of decision-making is done by themselves, 50.6% jointly with spouse, and 11.7% by the children on their behalf. For females, 24.6% of decision-making is done by themselves, 20.7% jointly with spouse, and 54.7% by the children on their behalf. The most significant difference is between decisions made on behalf of male and female elderly by their children. Combining the results, overall for the Bengali aged at this time joint decisions are the majority (35.7%), with decisions by children coming next (33.2%) and lastly self-driven decisions (31.2%), with only a 4.5% range between them all (78). Despite the decision-making models having quite rigid boundaries, excluding combinations that would allow for collaboration between parents and children for example, the data showing that joint spousal decisions predominate, and not proxy decisions, is an impressive result.
Bhowmik, one of the same investigators in the 1984 A.P. study, in the 2003 article “Indigenous Health Practices among the Digaru Mishmis of Arunachal Pradesh” showed only that patriarchs seek out medical treatment on behalf of family members since “[d]uring injuries and ailments of complicated nature, the professional medicine man is approached. The head of the family consult the local medical expert from among the villagers” (4).
Lastly, Behura’s 2003 article “Health culture, Ethnomedicine and Modern Medical Services” focuses on the “Saora, a major tribal group of the Indian state of Orissa” (27) and found that “[t]here are several factors which influence the decision-making process of the Saora. The first and foremost factor is their tradition and their confidence in the age-old mode of diagnosis and treatment of disease by their medicinemen” (54). As with the Ranchi and Nocte tribals there is reliance on local healers for traditional medicine treatment regimes. And like the Ranchi tribals, we can only surmise that there is a similar lack of familiarity with biomedicine that would hinder participation in treatment decisions in such fora.
Conclusion
With regard to judicial proceedings of malpractice suits against physicians in India, both Kumar and Nandimath agree that a paternalistic ‘doctor-centric’ model of decision-making has predominated and Kumar points to the principles of ‘reasonableness’ and ‘best interest’ being exploited for the purpose of protecting physicians from liability. The two scholars also agree that a shift towards patient autonomy is evident by an increase in malpractice suits and those that are ruled in the patient complainant’s favour. To autonomy I add that such a shift also increases the potential for more balanced collaborative decision-making. Nandimath also makes it clear that SDMs are chosen without much discrimination, which leaves open the possibility for proximal rather than closely-tied relations being chosen out of convenience rather than determining SDMs based on who would most likely have the patient’s best interests at heart.
Studies from the Journal of the Anthropological Survey of India had various results with regard to decision-making including: a prevalence of dependency among mentally ill patients in 1982 Calcutta; some autonomy with regard to biomedical treatment decisions among the Nocte of Arunachal Pradesh in 1984; utter disempowerment of tribals in 1997 Ranchi hospital decision-making due to lack of familiarity with biomedicine, the technical language of physicians, social stratification and gender relations; a significant difference between decisions made on behalf of female and male elderly by their children (higher for females with a 53% range) and an impressive predominance of joint spousal decisions among elderly Bengalis of Meghalaya in 2000; family patriarchs among the Digaru Mishmis of Arunachal Pradesh in 2003 seeking out medical treatment on behalf of family members; and finally, reliance on local healers for traditional medicine treatment regimes and a lack of familiarity with biomedicine among the Saora in 2003. Having briefly explored two textual genres within law and anthropology to begin to uncover health care decision-making in India, I found some temporal and spatial variation but, overall, many signs that patient autonomy has increasing value and that there is room for a collaborative middle-ground between doctor-centric and patient-centric models.
Citations
Banerjee, Mrinmayi. “Some Psycho-social Problems of Old Age among the Bengalis of Meghalaya.” Human Science: Journal of the Anthropological Survey of India 49 (2000): 69-82.
Behura, N.K. “Health culture, Ethnomedicine and Modern Medical Services.” Journal of the Anthropological Survey of India 52 (2003): 27-67.
Bhowmik, D.C. and Anadi Pal. “Indigenous Health Practices Among the Nocte of Arunachal Pradesh.” Human Science: Journal of the Anthropological Survey of India 33 (1984): 35-53.
Bhowmik, D.C. “Indigenous Health Practices among the Digaru Mishmis of Arunachal Pradesh.” Journal of the Anthropological Survey of India 52 (2003): 1-8.
Datta, Asha. “A Study of Diagnostic Patterns of Mental Illness in Calcutta Hospitals and their Relation to Some Social Variables.” Bulletin of the Anthropological Survey of India Vol. XXIX (1982): 85-97.
Health Care Consent Act (Canada), 1996 (As of August 31 2007).
Kumar, Jyotica Pragya. Informed Consent in Judicial Discourse: India and Canada 1996-2003. UMI Dissertations Publishing, 2005.
Kumari, Pratibha. “Health Hazards among the Tribals and their Cultural Cognition for Modern Medical System: A Case Study of Rajendra Medical College and Hospital, Ranchi.” Journal of the Anthropological Survey of India 46 (1997): 67-86.
Nandimath, Omprakash V. “Consent and Medical treatment: The Legal Paradigm in India.” Indian Journal of Urology: IJU: Journal of the Urological Society of India, V. 25 (3), (2009): 343-347.
Pietkiewicz, Igor. Culture, Religion, and Ethnomedicine: The Tibetan Diaspora in India. University Press of America, 2008.
2013
Introduction
The concern of my overall doctoral research project is the influence of religion on adherents’ views of health and disease/illness in contemporary India and how this affects health care decisionmaking, particularly those at the end-of-life. To begin to understand the processes of health care decision-making in India, both in theory and practice and with particular concern for the players involved and the respective power they wield, I will delve into two textual genres from within law and anthropology, and subdivide the paper accordingly. They are: (1) judicial proceedings, and (2) anthropological surveys.
Judicial Proceedings
Jyotica Pragya Kumar’s dissertation Informed Consent in Judicial Discourse: India and Canada 1996-2003 for a University of Toronto Sociology doctorate contains a chapter on “A Profile of the Doctor-Patient Relationship in India.” This section proved indispensable in beginning the process of discovering court proceedings that address the issue of health care decision-making in contemporary India. Kumar first establishes the nature of the doctor-patient relationship in India:
The relationship between the doctor and the patient is not a ‘contract of service’ - an expression which implies a master-servant relationship and involves an obligation to obey orders in the work to be performed and as its mode and manner of performance. A patient, on the other hand, cannot command the doctor to administer to him or her particular treatment if the same is not prescribed or approved by the latter. The relationship between the two is, at most, a ‘contract for service’, which signifies a contract whereby the doctor undertakes to render professional services, in the performance of which he is not subject to detailed direction and control by the patient. The doctor exercises professional judgment and uses his or her own knowledge and discretion quite independent of the patient (footnote 3: See Indian Medical Association v. V.P. Shanta and others, AIR 1998 Supreme Court 550 at 561 (para. 41) (26).
Within the context of this relationship, “a doctor’s professional decision-making functions are broadly divided into three phases: ‘diagnosis, advice and treatment’ (f16: Per Lord Bridge in Sidaway v. Bethlam Royal Hospital Governors and others, (1985) 1 All E.R. 643 (H.L.) at 660 c.)” (29). Although Kumar determines that “out of these, the functions relating to ‘diagnosis’ and ‘treatment’ have been clearly held to fall within the ambit of professional decision-making” (29), she distinguishes them from the phase of ‘advice’:
…the term ‘advice’ is used in a wider sense to cover “information as to risk and options of alternative treatment.”… Two lines of thinking, representing two different approaches, are in vogue. One view is that the determination of the doctor’s legal duty to advise is a matter of medical judgment, the professional decision-making. The other view is that this duty to advise cannot be left to the doctor’s judgment, because it is essentially a matter that impinges upon the right of a patient to ‘personal decision-making.’ India, following the English courts, has adopted the former approach, which gives primacy to the doctor’s decision-making for the patient; whereas…the latter approach…emphasizes the autonomy of the patient’s eventual decision-making… Since India has hitherto adopted the British approach, it would be in order to take note of the decision of the House of Lords in Sidaway, which gives primacy to the decision of the doctor over the patient (31-32).
With both the interpretation of “contract for service” in the Indian Medical Association case and “advice” in Sidaway lending judiciary strength to the physician’s independence in decision-making in India, we see not only the autonomy of the patient endangered but both collaborative and heteronomous decisionmaking models rendered difficult or impossible. I construe “collaborative decision-making” as that involving at least two parties, and “heteronomous decision-making” as that involving at least three parties having particular roles. My definition and usage of these terms will be explained in more detail in our case study later. From the Supreme Court ruling in relation to another case, Achutrao Haribhau Khodwa and others v. State of Maharashtra and others (AIR 1996 SC 2377), it is made “evident that the ambit of the decision-making authority of the doctor in India is very wide and almost unrestricted. This is amply clear as a matter of law as well as practice that if, in a given case, more than one course of treatment may be available for treating a patient, it is the doctor, and not the patient, who decides which course is to be adopted” (37). With one qualifier rendered useless by context specificity, Kumar concludes that the predominant decision-making model leaves all of the power in the hands of the physician:
The only restraint is that he ‘must bring to his task a reasonable degree of skill and knowledge and must exercise a reasonable degree of care.’ For meeting the standard of ‘reasonableness’, what is expected of the doctor is neither ‘the very highest’ nor a ‘very low degree’ of care and competence, judged in the light of the particular circumstances of each case. This is ‘what the law requires’ in India, and this is the law, which has been again affirmed by the Supreme Court recently in Vinitha Ashok v. Lakshmi Hospital… We may describe this approach as ‘doctor-centric’ (37-38).
In addition to the unclear nature of ‘reasonableness,’ the principle of ‘best interest’ is mobilized to protect doctors during litigation. During a 1991 appeal in the case of M.K. Verghese v. San Joc Hospital (39), the court’s observation “reflects the predominance of the ‘doctor-centric’ approach” since “‘informed consent’ in India just means informing the patient what the attending doctor did or intended to do in the best interest of the patient without the necessity of having any return response from him or her (patient)” (43). A trend crippling to both autonomy and collaboration in decision-making, Kumar’s “analysis of the Indian cases reveals that, hitherto, the patient’s autonomy to decide for himself or herself is completely absorbed into the decision-making authority of the doctor” (44). She notes, however, that the trend is shifting:
…the smooth functioning of doctor-patient relationship seems to be premised on the unwritten understanding of patient’s complete faith, trust and confidence in the capability of the doctor. However, cases have started coming to the courts, increasing in number, showing a questioning of doctor’s authority, which until relatively recently, was beyond reproach… [With] increasing awareness of the people at large generally, and the patient population in particular about their rights…[, there is a new] trend of asserting rights against doctors, and thereby changing their paternalistic attitude (46-47). Another judicial move found in Chandra Shukla v Union of India (AIR 1987 ACJ 628) and mentioned by Omprakash V.Nandimath of the National Law School of India University in Bangalore, has hindered the paternalism of Indian doctors:
For the fist time in India, the court ruled that however broad consent might be for diagnostic procedure, it can not be used for therapeutic surgery. Furthermore, the court observed that "where the consent by the patient is for a particular operative surgery it can't be treated as consent for an unauthorized additional procedure involving removal of an organ only on the ground that it is beneficial to the patient or is likely to prevent some danger developing in the future, where there is no imminent danger to the life or health of the patient". This proposition puts fetter upon the role of a "paternal doctor" in the Indian scenario. (344)
In addition to Kumar’s assessment that such “development signals that the society in India has also started moving gradually in the direction of individual autonomy” (49), I hold that it also paves the way for collaborative decision-making models to make their way into Indian hospitals.
Despite a discussion on the increase of malpractice suits against physicians, strangely Kumar does not give any examples of courts ruling in favour of patient complainants in malpractice suits against physicians, which supports her argument that although moving towards patient autonomy, consent and decision-making remains doctor-centric. However, Nandimath cites Maneka Gandhi v Union of India (AIR 1978 SC 597) in which the courts ruled in the patient’s favour. This case is very similar to many cited by Kumar where the scenario has a surgeon opening up a patient to deal with one organ in a particular way and removes another organ without consent because it is found to be unhealthy. The crucial difference in this case is the removal of the unhealthy organ led to another organ being compromised. Nandimath also attempts to broach the topic of the processes of ranking of Substitute Decision-makers (SDM) but without any evidence since judicial or institutional regulations that might control the practice are absent: “Regarding proxy consent, when the patient is unable to give consent himself, there are no clear regulations or principles developed in India. If such a situation exists, the medical practitioner may proceed with treatment by taking the consent of any relative of the patient or even an attendant” (345, emphasis added). Without a legal ranking of SDMs the danger that I can see is that relatives that are close by way of proximity rather than by relation might be treated as SDMs. In ranking SDMs, Canada’s Health Care Consent Act favours spouses, partners and relatives in descending order with regard to decisionmaking. ‘Spouses’ are defined by marriage, co-habitation, or having a child together (c.2, Sched. A, s. 59.7), whereas ‘partners’ are defined as those with a “close personal relationship that is of primary importance in both persons’ lives” (c.18, Sched. A, s. 10) and would of course accommodate same-sex couples. These relationships are given prominence by the legislation. Next, ‘relatives’ are defined by “blood, marriage or adoption” (c.2, Sched. A, s. 20.10). In theory, the logic behind privileging close kin as defined by the patient is to get as close to possible to the patient’s autonomous wishes in determining courses of action that are in their best interests. Despite such legislation, in practice I have observed too many times to count that those close to the incompetent patient in proximity are the main source accessed by health care teams during difficult decisions. Igor Pietkiewicz, a Polish medical anthropologist in Tibetan Studies, notes that “[h]ierarchy and subordination within technomedicine is expressed in the relationship between individual and institution, in which hospital routines are subject to the convenience of the medical staff, not the patient” (Pietkiewicz 39). This is often the case with regard to decisionmaking in Toronto hospitals. It is simply easier to make decisions with people physically present regardless of where they fall in the hierarchy of suitable SDMs. This practice of accessing proximal patient relations over those with degrees of closeness, which I have observed in many hospital contexts but particularly within critical care areas such as Emergency and Intensive Care where lives usually hang in the balance, is exacerbated by time-constraints, degree of seriousness of the patient condition and language barriers. Nandimath points to a conflation of spouses, partners and relatives by blood, marriage or adoption with the term “relatives” in an Indian health care context.
Anthropological Surveys
Mining the Journal of the Anthropological Survey of India for articles related to health and decision-making yielded some interesting data spanning two decades. Articles of interest cluster in the early eighties and around the cusp of the new millennium, and I will address them chronologically. I have left spelling and grammatical errors from the original articles intact and have not indicated such mistakes save for one glaring mispelling.
In Asha Datta’s 1982 article “A Study of Diagnostic Patterns of Mental Illness in Calcutta Hospitals and their Relation to Some Social Variables,” the investigator attempts to uncover the “belief about mental illness held by persons coming into contact with the ‘mentally ill’” since it “is of significance in proper diagnosis, prompt treatment and effective aftercare of the patients” (85). Informants were “the relatives of some of the out-patients” and “were approached to assess their belief about mental illness and their attitude towards their respective patients” (86). As was found in Nandimath with regard to the term ‘relatives’ in substitute decision-making, the various types of these relationships are not distinguished. The questionnaire results were subdivided into several models. Within the “Family model…There are many who…ascribe to the belief that the family is responsible for the illness and cure of mental patients” (93). The “Intrapersonal model” showed that some “agree that the patient is responsible for his own condition; and cure,” and in the “Social model…90% of [respondents] hold the society responsible for the treatment” (94). As shown above, the lack of symmetry in the presentation of results makes it difficult to say much other than most adhere to the ‘social model’ and people to a greater or lesser degree hold to the others. It is also not made clear what is meant by either ‘society’ or ‘responsibility.’ Does the former include private citizens, health care professionals and institutions as well as governmental bodies? Does the latter include both resources and decisions? Another statement not made entirely clear is the finding that “[t]he attitude of relatives of patients is benign,” but could mean that relatives do not begrudge the mentally ill family member for the burden their illness bears on them since “[t]he patient is viewed mostly as dependent” (95). This at least tells us that in 1982 Calcutta, decisions were more likely to be made by those other than the mentally ill patient themselves. We can surmise that competence would have much to do with this.
Bhowmik and Pal’s 1984 “Indigenous Health Practices Among the Nocte of Arunachal Pradesh” focuses on a group that “occupies the Central part of the Tirap District of Arunachal Pradesh numbering 24, 292 according to 1971 Census” (36). Regarding “Disease and treatment … Generally the professional expert among them is consulted in case of long suffering or any complication. The medicineman prescribes material of either plant or animal origin” (41). There is no mention of any negotiation around prescriptions so it might be safe to say that such decisions for traditional treatments are made by such healers for the patient. However, in the context of the “Impact of Modernization” the investigators found that “[i]n most of the injury cases, the Nocte like stitching which is done in the hospital” and that “[n]ow-a-days the Nocte prefer injection than oral medicines. The idea prevails that in injection entire medicine is accepted in body whereas in oral medicines some may go out of body through body secretions” (51). This indicates to me some degree of autonomy exerted among this group in relation to biomedical health care professionals as they seek out particular interventions, and accept certain treatments and refuse others.
In Kumari’s 1997 “Health Hazards among the Tribals and their Cultural Cognition for Modern Medical System: A Case Study of Rajendra Medical College and Hospital, Ranchi,” tribal use of hospital interventions is again investigated but this time in the second most populous city in the state of Jharkhand. One of the researcher’s main findings is significant to decision-making, but not surprising:
...in the hospital, there exists communication gap between the poor illiterate patients and specialists…. One of the important reasons why the tribals use folk modes of health care, because the patients and his relatives feel they can talk more freely to folk medicinemen than with modern physician. The interpersonal relationship between tribals and folk practitioners on one hand and the rural tribals and modern medical practitioner on the other hand are considerably different. Thus there exists a communication gap on emotional plane in the hospital between the patients and professionals.
On the contrary to the indigenous medical practices, western system of medicine is alien to the cultural pattern of the rural folk. Modern doctors fail to lounch [sic] their scientific advice in terms which fit on already existing cultural pattern creating gap on cultural plane. Thirdly, practitioners of modern medicine come from well to do families. By their education and training they tend to be sophisticated. This leave a gap between intellectual level of the practitioners and the illiterate patients. There is an enormous social distance between the two groups (83).
In this case, patients are disempowered in decision-making processes due to several factors: lack of familiarity with biomedicine; technical language usage by physicians; and social stratification. The article concludes with the recommendation that “[t]he health care system has therefore to be deprofessionalize…to provide better services to poor masses…” and among nine suggestions gives this: “Efforts should be made to fit the practice of medicine to the role that is appropriate to social system of the tribal people. Educated young tribals of both sexes should be recruited as health staff in health centres who will able to understand their own affairs promptly” (84). Although not elaborated upon, obstacles arising from gender relations is a notable concern.
Banerjee’s “Some Psycho-social Problems of Old Age among the Bengalis of Meghalaya” in 2000 “tries to highlight the role of Bengali aged people in the family in terms of decision-making processes” (69). It is unfortunate that health care decisions were not included in this survey. Regardless, it was found that:
It is generally believed that in changing life-style and increase in average longevity, the aged people in the present time are not enjoying the same respect and position as their predecessors used to enjoy in their days. With this view in mind we have examined in this section to what extent their opinions are being valued in family affairs like (i) financial matter, (ii) marriage of children, (iii) children’s education, iv) participation in social activities (77).
Although not done in the article, I extrapolated the results by combining all family affairs. There is a great discrepancy based on gender. For males, 37.7% of decision-making is done by themselves, 50.6% jointly with spouse, and 11.7% by the children on their behalf. For females, 24.6% of decision-making is done by themselves, 20.7% jointly with spouse, and 54.7% by the children on their behalf. The most significant difference is between decisions made on behalf of male and female elderly by their children. Combining the results, overall for the Bengali aged at this time joint decisions are the majority (35.7%), with decisions by children coming next (33.2%) and lastly self-driven decisions (31.2%), with only a 4.5% range between them all (78). Despite the decision-making models having quite rigid boundaries, excluding combinations that would allow for collaboration between parents and children for example, the data showing that joint spousal decisions predominate, and not proxy decisions, is an impressive result.
Bhowmik, one of the same investigators in the 1984 A.P. study, in the 2003 article “Indigenous Health Practices among the Digaru Mishmis of Arunachal Pradesh” showed only that patriarchs seek out medical treatment on behalf of family members since “[d]uring injuries and ailments of complicated nature, the professional medicine man is approached. The head of the family consult the local medical expert from among the villagers” (4).
Lastly, Behura’s 2003 article “Health culture, Ethnomedicine and Modern Medical Services” focuses on the “Saora, a major tribal group of the Indian state of Orissa” (27) and found that “[t]here are several factors which influence the decision-making process of the Saora. The first and foremost factor is their tradition and their confidence in the age-old mode of diagnosis and treatment of disease by their medicinemen” (54). As with the Ranchi and Nocte tribals there is reliance on local healers for traditional medicine treatment regimes. And like the Ranchi tribals, we can only surmise that there is a similar lack of familiarity with biomedicine that would hinder participation in treatment decisions in such fora.
Conclusion
With regard to judicial proceedings of malpractice suits against physicians in India, both Kumar and Nandimath agree that a paternalistic ‘doctor-centric’ model of decision-making has predominated and Kumar points to the principles of ‘reasonableness’ and ‘best interest’ being exploited for the purpose of protecting physicians from liability. The two scholars also agree that a shift towards patient autonomy is evident by an increase in malpractice suits and those that are ruled in the patient complainant’s favour. To autonomy I add that such a shift also increases the potential for more balanced collaborative decision-making. Nandimath also makes it clear that SDMs are chosen without much discrimination, which leaves open the possibility for proximal rather than closely-tied relations being chosen out of convenience rather than determining SDMs based on who would most likely have the patient’s best interests at heart.
Studies from the Journal of the Anthropological Survey of India had various results with regard to decision-making including: a prevalence of dependency among mentally ill patients in 1982 Calcutta; some autonomy with regard to biomedical treatment decisions among the Nocte of Arunachal Pradesh in 1984; utter disempowerment of tribals in 1997 Ranchi hospital decision-making due to lack of familiarity with biomedicine, the technical language of physicians, social stratification and gender relations; a significant difference between decisions made on behalf of female and male elderly by their children (higher for females with a 53% range) and an impressive predominance of joint spousal decisions among elderly Bengalis of Meghalaya in 2000; family patriarchs among the Digaru Mishmis of Arunachal Pradesh in 2003 seeking out medical treatment on behalf of family members; and finally, reliance on local healers for traditional medicine treatment regimes and a lack of familiarity with biomedicine among the Saora in 2003. Having briefly explored two textual genres within law and anthropology to begin to uncover health care decision-making in India, I found some temporal and spatial variation but, overall, many signs that patient autonomy has increasing value and that there is room for a collaborative middle-ground between doctor-centric and patient-centric models.
Citations
Banerjee, Mrinmayi. “Some Psycho-social Problems of Old Age among the Bengalis of Meghalaya.” Human Science: Journal of the Anthropological Survey of India 49 (2000): 69-82.
Behura, N.K. “Health culture, Ethnomedicine and Modern Medical Services.” Journal of the Anthropological Survey of India 52 (2003): 27-67.
Bhowmik, D.C. and Anadi Pal. “Indigenous Health Practices Among the Nocte of Arunachal Pradesh.” Human Science: Journal of the Anthropological Survey of India 33 (1984): 35-53.
Bhowmik, D.C. “Indigenous Health Practices among the Digaru Mishmis of Arunachal Pradesh.” Journal of the Anthropological Survey of India 52 (2003): 1-8.
Datta, Asha. “A Study of Diagnostic Patterns of Mental Illness in Calcutta Hospitals and their Relation to Some Social Variables.” Bulletin of the Anthropological Survey of India Vol. XXIX (1982): 85-97.
Health Care Consent Act (Canada), 1996 (As of August 31 2007).
Kumar, Jyotica Pragya. Informed Consent in Judicial Discourse: India and Canada 1996-2003. UMI Dissertations Publishing, 2005.
Kumari, Pratibha. “Health Hazards among the Tribals and their Cultural Cognition for Modern Medical System: A Case Study of Rajendra Medical College and Hospital, Ranchi.” Journal of the Anthropological Survey of India 46 (1997): 67-86.
Nandimath, Omprakash V. “Consent and Medical treatment: The Legal Paradigm in India.” Indian Journal of Urology: IJU: Journal of the Urological Society of India, V. 25 (3), (2009): 343-347.
Pietkiewicz, Igor. Culture, Religion, and Ethnomedicine: The Tibetan Diaspora in India. University Press of America, 2008.
Thursday, March 6, 2014
Medical Marijuana and Buddhism
Below is the full text submitted for the article "How do Buddhists view medical marijuana?" in The Medical Marijuana Review Posted on January 2, 2014 by Dave Gordon in Feature Story. http://medireview.com/2014/01/how-do-buddhists-view-medical-marijuana/#.UuffYxb0DUT
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Medical Marijuana and Buddhism
Sean Hillman, PhD student Religion/Bioethics/South Asian Studies
University of Toronto
Dec. 10, 2013
Since Buddhism is multiple, it is difficult to establish an authoritative stance on many issues. My thoughts on this particular subject are merely my opinion, informed by the study and practice of Buddhist discipline texts and caregiving in hospice and hospital settings. His Holiness the Dalai Lama's recent statement on the medicinal use of marijuana points to one of the central concerns when determining the appropriateness of Buddhists using certain medications: whether it is mood/mind/consciousness altering or not. As with other such statements on major issues, I think this is meant to address Buddhist vow-holders (householders and monastics who have chosen to keep ethical precepts, including to abstain from intoxicants) in particular and is not best served as a blanket statement applying to all since what people choose to ingest is their private business not subject to Buddhist religious scrutiny. What the individual ingests is, however, indeed under the scrutiny of the law and the health care professional that is responsible for suggesting courses of treatment for the patient. A similar tension between treating illness versus altering the mind occurs regularly with front-line Emergency Room professionals when drug addicts seek treatment. It is difficult to tease out a valid need for somatic pain relief from simple drug-seeking, and many health studies show that this complexity results in an under-treatment of pain in relation to this demographic. The concern with intoxicating side-effects when using opioids, such as morphine for example, is often based on a misunderstanding of pain management. Simply, when the pain at hand is addressed without any intoxicating side-effects, medication has been administered correctly and pain management is effective. Finding the best delivery method and dosage are the challenges. If there is intolerable pain, it is not yet managed. Going beyond this threshold can lead to side-effects, including drowsiness and even respiratory failure. This is often cited in articles on Buddhism and health care as the reason why Buddhist patients might refuse pain management when nearing death for fear that they will not be able to die with conscious awareness and thus detrimentally affect their rebirth. Earlier in my career as a Buddhist, especially while a monastic, I would likely have similarly refused pain control meds. Now, however, I know that there are circumstances in which medicinal pain management can be done properly and actually serve as an essential component for assisting the Buddhist with intractable pain to die more comfortably without loss of awareness.
If we apply pain management logic to the use of medical marijuana by Buddhist vow-holders, I would ask if it is possible to treat illness by this means without side-effects. It is well established that chronic cannabis users develop a tolerance which requires a certain amount to normalize, or level-out to counteract possible unwanted emotional states such as depression or agitation, and have increasing difficulty in achieving a high. In such cases of dependency it seems possible to use the drug without altering the mind. But what about someone who is not dependent and is prescribed medical marijuana for pain associated with cancer, as it often is, or asthma? And what about the differences between delivery methods, such as edibles versus smoking, or smoking versus vaporizing? I would say that in comparison to opioids where pain management can be achieved without side-effects, the side-effects from medical marijuana are more difficult to avoid. This may simply be a matter of delivery and dosage and not inherent in the chemistry of the drug. It is interesting that, as far as I am aware, patients themselves are exclusively responsible for self-administering the marijuana prescribed to them. Envision patients sitting with an IV being administered THC right into the blood-stream, or being given THC pills. The degree to which we find this fanciful might be commensurate with the degree to which we have trouble disentangling the botanical as a therapeutic intervention from it as a recreational drug.
If Buddhist goals are the development of a calmly stabilized mind with insight into reality and a heart concerned deeply with others for their own sake, then actions that hinder these processes, such as altering the mind with substances and potentially increasing delusions and emotional afflictions (while breaking vows to do so), are obstacles on the various Buddhist paths. Here I distinguish between Buddhists who hold a vow to refrain from intoxicants and those who do not. Even if a vow-holder would refrain from using medical marijuana if they could not establish for certain that their complaint could be successfully addressed without mood/mind/consciousness altering side-effects, this does not mean that non-vow-holding Buddhists do not use marijuana both recreationally and therapeutically. There is nobody disciplining Buddhists except for the practitioner themselves, and the natural law of karma is considered to operate whether the practitioner is aware or concerned with the process or not.
I have entirely avoided discussion of tantric traditions where typically forbidden substances are consumed as a subversive against pollution taboos and to demonstrate transcendence of materiality. I have also chosen to bracket the occasions of sacred usage of botanicals explicitly for spiritual purposes, such as with ayahuasca during ceremony. Both of these areas of inquiry can potentially add to the discourse around medical marijuana and Buddhism.
==
Sat. Apr. 5
Zysk's study of ancient Indian medicine in Buddhist monastic and Hindu texts shows that intoxicants were at times doctrinally acceptable (by way of sanction by the Buddha) for use in treating monastics suffering from certain conditions despite the seeming contradiction with the vow to abstain from intoxicants. There are two examples found in the case stories of disease treatment in the medicine section of the Theravada Pali monastic code.
(1)
"Affictions of Wind: The monk Pilindavaccha suffered from the affliction of wind (vātābādha). On the recommendation of physicians (vejja, Skt. vaidya) oil (tela) was decocted, combined with a weakened intoxicating drink (majja, Skt. mada, madya), and given to the monk. If the drink was too strong, an oily massage (abbhañjana) was to be administered (Zysk 1991: 92)."
(2)
"Wind in the Abdomen: The affliction of wind in the abdomen (udaravātā) is discussed two times in the Vinaya. In the first case, a monk was cured by giving a mixture of salt and a type of astringent barley wine (loṇasovīraka) to drink. This treatment was allowed to the sick (gilāna), but for those not sick (agilāna), it was permitted as a drink (pāna) when mixed with water (udakasambhinna) (Zysk 1991: 100)."
It is interesting to note that mention of the medicinal use of intoxicating substances in both cases does not have explicit reference to neutralizing the intoxicating potential, but merely calls for a 'weakened' form of the drink for the sick monastic in the first case but not in the second, and dilution of the barely wine concoction for the healthy monastic. We could assume that the 'weakened' form is prepared by dilution, but that is not entirely made clear. Nor is it clear that the 'weakened' form of the first concoction is made to no longer have the potential to cause intoxication. The many examples of special exceptions for sickness in the monastic codes, such as flexibility around eating after midday, might explain the specific use of concoctions with intoxicants for sick monastics but why would healthy monks take a diluted form of the second concoction? We could assume that the need for dilution in this case would be to prevent intoxication, and that healthy monastics would be taking it as a prophylactic treatment (not just for the sake of it), but neither of these assumptions have explicit textual support. Buddhaghosa's Vishuddhimagga ("Path of Purification"), which Zysk relies on in his study, might help clarify these points. In his commentary on these cases Zysk doesn't seem to find this fascinating tension between the competing principles in the monastic code of maintaining clear-mindedness versus treating illness at all noteworthy. I also wonder what this "intoxicating drink (majja, Skt. mada, madya)" is, and if it is related to honey based on linguistic similarity. I will be looking into it.
==
Medical Marijuana and Buddhism
Sean Hillman, PhD student Religion/Bioethics/South Asian Studies
University of Toronto
Dec. 10, 2013
Since Buddhism is multiple, it is difficult to establish an authoritative stance on many issues. My thoughts on this particular subject are merely my opinion, informed by the study and practice of Buddhist discipline texts and caregiving in hospice and hospital settings. His Holiness the Dalai Lama's recent statement on the medicinal use of marijuana points to one of the central concerns when determining the appropriateness of Buddhists using certain medications: whether it is mood/mind/consciousness altering or not. As with other such statements on major issues, I think this is meant to address Buddhist vow-holders (householders and monastics who have chosen to keep ethical precepts, including to abstain from intoxicants) in particular and is not best served as a blanket statement applying to all since what people choose to ingest is their private business not subject to Buddhist religious scrutiny. What the individual ingests is, however, indeed under the scrutiny of the law and the health care professional that is responsible for suggesting courses of treatment for the patient. A similar tension between treating illness versus altering the mind occurs regularly with front-line Emergency Room professionals when drug addicts seek treatment. It is difficult to tease out a valid need for somatic pain relief from simple drug-seeking, and many health studies show that this complexity results in an under-treatment of pain in relation to this demographic. The concern with intoxicating side-effects when using opioids, such as morphine for example, is often based on a misunderstanding of pain management. Simply, when the pain at hand is addressed without any intoxicating side-effects, medication has been administered correctly and pain management is effective. Finding the best delivery method and dosage are the challenges. If there is intolerable pain, it is not yet managed. Going beyond this threshold can lead to side-effects, including drowsiness and even respiratory failure. This is often cited in articles on Buddhism and health care as the reason why Buddhist patients might refuse pain management when nearing death for fear that they will not be able to die with conscious awareness and thus detrimentally affect their rebirth. Earlier in my career as a Buddhist, especially while a monastic, I would likely have similarly refused pain control meds. Now, however, I know that there are circumstances in which medicinal pain management can be done properly and actually serve as an essential component for assisting the Buddhist with intractable pain to die more comfortably without loss of awareness.
If we apply pain management logic to the use of medical marijuana by Buddhist vow-holders, I would ask if it is possible to treat illness by this means without side-effects. It is well established that chronic cannabis users develop a tolerance which requires a certain amount to normalize, or level-out to counteract possible unwanted emotional states such as depression or agitation, and have increasing difficulty in achieving a high. In such cases of dependency it seems possible to use the drug without altering the mind. But what about someone who is not dependent and is prescribed medical marijuana for pain associated with cancer, as it often is, or asthma? And what about the differences between delivery methods, such as edibles versus smoking, or smoking versus vaporizing? I would say that in comparison to opioids where pain management can be achieved without side-effects, the side-effects from medical marijuana are more difficult to avoid. This may simply be a matter of delivery and dosage and not inherent in the chemistry of the drug. It is interesting that, as far as I am aware, patients themselves are exclusively responsible for self-administering the marijuana prescribed to them. Envision patients sitting with an IV being administered THC right into the blood-stream, or being given THC pills. The degree to which we find this fanciful might be commensurate with the degree to which we have trouble disentangling the botanical as a therapeutic intervention from it as a recreational drug.
If Buddhist goals are the development of a calmly stabilized mind with insight into reality and a heart concerned deeply with others for their own sake, then actions that hinder these processes, such as altering the mind with substances and potentially increasing delusions and emotional afflictions (while breaking vows to do so), are obstacles on the various Buddhist paths. Here I distinguish between Buddhists who hold a vow to refrain from intoxicants and those who do not. Even if a vow-holder would refrain from using medical marijuana if they could not establish for certain that their complaint could be successfully addressed without mood/mind/consciousness altering side-effects, this does not mean that non-vow-holding Buddhists do not use marijuana both recreationally and therapeutically. There is nobody disciplining Buddhists except for the practitioner themselves, and the natural law of karma is considered to operate whether the practitioner is aware or concerned with the process or not.
I have entirely avoided discussion of tantric traditions where typically forbidden substances are consumed as a subversive against pollution taboos and to demonstrate transcendence of materiality. I have also chosen to bracket the occasions of sacred usage of botanicals explicitly for spiritual purposes, such as with ayahuasca during ceremony. Both of these areas of inquiry can potentially add to the discourse around medical marijuana and Buddhism.
==
Sat. Apr. 5
Zysk's study of ancient Indian medicine in Buddhist monastic and Hindu texts shows that intoxicants were at times doctrinally acceptable (by way of sanction by the Buddha) for use in treating monastics suffering from certain conditions despite the seeming contradiction with the vow to abstain from intoxicants. There are two examples found in the case stories of disease treatment in the medicine section of the Theravada Pali monastic code.
(1)
"Affictions of Wind: The monk Pilindavaccha suffered from the affliction of wind (vātābādha). On the recommendation of physicians (vejja, Skt. vaidya) oil (tela) was decocted, combined with a weakened intoxicating drink (majja, Skt. mada, madya), and given to the monk. If the drink was too strong, an oily massage (abbhañjana) was to be administered (Zysk 1991: 92)."
(2)
"Wind in the Abdomen: The affliction of wind in the abdomen (udaravātā) is discussed two times in the Vinaya. In the first case, a monk was cured by giving a mixture of salt and a type of astringent barley wine (loṇasovīraka) to drink. This treatment was allowed to the sick (gilāna), but for those not sick (agilāna), it was permitted as a drink (pāna) when mixed with water (udakasambhinna) (Zysk 1991: 100)."
It is interesting to note that mention of the medicinal use of intoxicating substances in both cases does not have explicit reference to neutralizing the intoxicating potential, but merely calls for a 'weakened' form of the drink for the sick monastic in the first case but not in the second, and dilution of the barely wine concoction for the healthy monastic. We could assume that the 'weakened' form is prepared by dilution, but that is not entirely made clear. Nor is it clear that the 'weakened' form of the first concoction is made to no longer have the potential to cause intoxication. The many examples of special exceptions for sickness in the monastic codes, such as flexibility around eating after midday, might explain the specific use of concoctions with intoxicants for sick monastics but why would healthy monks take a diluted form of the second concoction? We could assume that the need for dilution in this case would be to prevent intoxication, and that healthy monastics would be taking it as a prophylactic treatment (not just for the sake of it), but neither of these assumptions have explicit textual support. Buddhaghosa's Vishuddhimagga ("Path of Purification"), which Zysk relies on in his study, might help clarify these points. In his commentary on these cases Zysk doesn't seem to find this fascinating tension between the competing principles in the monastic code of maintaining clear-mindedness versus treating illness at all noteworthy. I also wonder what this "intoxicating drink (majja, Skt. mada, madya)" is, and if it is related to honey based on linguistic similarity. I will be looking into it.
Wednesday, March 5, 2014
Religious Rights vs the Business & Politics of Green Energy
Thoughts on the dispute between Cham Shan Buddhist Temple and the Sumac Ridge Wind Project (wpd Canada)/Ministry of the Environment over Industrial Wind Turbines in the Kawarthas
After recent news coverage on the issue in the National Post, a post went up on the Sumeru Canadian Buddhism blog siding with the Ministry of Environment's decision to approve the building of Industrial Wind Turbines by wpd Canada in the Oak Ridges Moraine despite a lack of local support for the project. Push back by the Cham Shan Chinese Buddhist community, who have been developing a retreat centre in the area, has led to an appeal of the decision. At first glance this may seem like a clear case of choosing between green energy or the religious practice of meditation, but choosing to side with the Cham Shan Buddhist community (and other locals, including First Nations communities and the Peterborough airport) is not choosing against the environment. After some reflection, I posted a response clarifying my position. The link to the blog post and the text from my response can be found below:
http://www.sumeru-books.com/2014/02/national-post-catches-wind-ontario-controversy-buddhist-retreat/
After recent news coverage on the issue in the National Post, a post went up on the Sumeru Canadian Buddhism blog siding with the Ministry of Environment's decision to approve the building of Industrial Wind Turbines by wpd Canada in the Oak Ridges Moraine despite a lack of local support for the project. Push back by the Cham Shan Chinese Buddhist community, who have been developing a retreat centre in the area, has led to an appeal of the decision. At first glance this may seem like a clear case of choosing between green energy or the religious practice of meditation, but choosing to side with the Cham Shan Buddhist community (and other locals, including First Nations communities and the Peterborough airport) is not choosing against the environment. After some reflection, I posted a response clarifying my position. The link to the blog post and the text from my response can be found below:
http://www.sumeru-books.com/2014/02/national-post-catches-wind-ontario-controversy-buddhist-retreat/
"Respectfully and in the spirit of dialogue, I have to disagree with your position. The issue, in my opinion, is not green energy versus meditation as you have framed it. I find this quite misleading. No one in the Cham Shan camp is contesting the benefits of green energy and their request to overturn the decision for the wind-farm in close proximity to the retreat development is not out of accord with the Dharma. You make it seem that a decision in their favour is a decision against the environment. I refute this. As is well known, the retreat project has decades of planning and tens of millions of dollars invested, and the building has begun, whereas the proposed wind-farm can be located elsewhere. There are tracts of land not close to human habitation where this wind-farm can be placed and still help feed the area's energy grid, doubtless a positive thing despite the Sumac Ridge Wind project being a for-profit venture by the wpd Canada company. You suggest that the retreat project is not in jeopardy, but what you might not have considered is that the nature of projects by non-profit charitable organizations are such that deviation from the original plans can in fact jeopardize their funding. The retreat project is very much in jeopardy.
To me, the issue is instead arm's-length provincial political leadership versus on-the-ground local voices in decision-making. It appears as an eco-win for Liberals for the wind project to get the go-ahead, and the PCs conveniently re-affirm commitment to scrap green energy act (see http://freewco.blogspot.ca/201... ) saying that "[t]he Green Energy Act is disastrous for rural Ontarians who live near these intrusive developments." Political wrangling aside, in this particular case, the local voices of minority religious and cultural groups, the Cham Shan Chinese Buddhist community and local Aboriginal communities, were quashed by the decision to approve the wind project. Reconciliation processes might lead us to think that we have progressed beyond the historical violence against minority groups in Canada, especially First Nations, but we are still in a climate that is hardly progressive when we consider the fact that federal spending on spiritual care services for non-mainstream religions has been recently cut. Or considering the over-representation of Aboriginal people in the Canadian Justice System with First Nations people comprising over 25% of the penal population but only 4% of Canadian population. These are but two terrible examples of how far we have to go to achieve fair and equitable treatment of minority groups in Canada.
You are quite right that the resistance has to do with the community's position that the wind-farm will disrupt their practice of meditation (within which I include pilgrimage between the sites in the retreat development). This is in accord with the Dharma as there is a pan-Buddhist injunction to have a beautiful and peaceful environment as support for meditation pursuits, as seen for example in the texts of Northern School Buddhist Masters Shantideva (Indian), Tsong Khapa (Tibetan), and Zhiyi (Chinese) to name but a few. Beauty is in the eye of the beholder. Your statement that "[p]ersonally, I feel if I were there, the sight of windmills would be very uplifting" assumes that the experience of an outsider to the Cham Shan Chinese Buddhist community would be the same as theirs. It questions the validity of their experience of industrial wind turbines as an interference to their practice. They are entitled to their experience. The construction of 19 industrial wind-turbines will create noise and particulates, and their subsequent operation will create infrasound and is considered by the community as unsightly. This is a strong enough reason for their appeal, on the basis of religious rights and freedoms, without even wading into the issue of harm to humans and animals by industrial wind-turbines. The research that I have uncovered show the harms to birds as existent but statistically low, and although some qualitative research into infrasound shows disturbances to meditators, quantitative research seems inconclusive. This does not mean that there are no empirically measurable health hazards, but rather, that the phenomenon of industrial wind turbine generated energy is young and the research as to its immediate and long-term effects on life even younger.
I fully support the Cham Shan appeal for the Ministry to overturn the approval given to the Sumac Ridge Wind project. In full disclosure, I am serving as an expert witness for the upcoming tribunal. However, my view of the situation is not the result of my acting in this capacity, but rather I am acting in this capacity because of my view.
Thank you for the forum for this discussion.
Sincerely,
Sean Hillman
PhD student, Religion/Bioethics/South Asian Studies
Department for the Study of Religion
University of Toronto"
PhD student, Religion/Bioethics/South Asian Studies
Department for the Study of Religion
University of Toronto"
Tuesday, January 28, 2014
How do Buddhists view medical marijuana? The Medical Marijuana Review January 2, 2014. Feature Story by Dave Gordon
When the Dalai Lama recently revealed his support for the use of medical marijuana, advocates of the drug discovered they had a new ally. But are the Dalai Lama’s views on medical cannabis breaking rank with the traditional Buddhist stance? Or are Buddhists generally in favour of medical marijuana as well?
Primary to the debate is what Buddhism calls the “five precepts”: refrain from taking life, don’t take what’s not yours, avoid sexual misconduct, don’t speak falsehoods, and avoid intoxicants.
It’s the last precept that’s a sticking point when it comes to medical marijuana.
Rev. Dr. Bhante Saranapala, a Buddhist monk and preacher working at the West End Buddhist Temple and Meditation Centre in Mississauga, Ontario, contends that the fifth precept forbids marijuana in any form.
“The five precepts are moral principles, and one of them is to refrain from intoxicants. If any substance leads to heedlessness, or could make one unconscious, you have to refrain, regardless of whether you think it’s good,” he says. “It alters the pure nature of the mind.”
The possibility exists, he added, that “you would not understand what you’re doing, or what you’re saying (while high). That’s why this is distinct.”
Historically there are few, if any, references in Buddhism regarding marijuana as a medicine, according to an article on Beliefnet.com.
Yet, the San Francisco Patient and Resource Center notes that Buddhists have used cannabis in tandem with meditation practices “as a means to stop the mind and enter into a state of profound stillness, also called Samadhi.” They add: “Various spiritual texts, including the Buddhist Tara Tantra, list cannabis as an important aide [sic] to meditation and spiritual practice.”
One source notes that Buddha himself believed cannabis was a cure for rheumatism.
Brian Ruhe, of the Theravada Buddhist Community of Vancouver, sides with the Dalai Lama on the issue.
“I’m in favor of [medical marijuana] as well. I explain it by saying the idea of medical marijuana is reducing suffering, and reducing suffering is good. In this case it’s reasonable, showing intelligent use for that situation,” he adds.
Ruhe has been a practicing Buddhist for 22 years and spent seven months as a Buddhist monk in Thailand in 1996.
“Medical marijuana is OK because Buddhism is a path of intelligence, discernment and compassion, not just following rules,” he contends.
“The Buddha said his teachings were not internally inconsistent because sometimes he would say one thing to a person, and something else to someone else. This is an example.”
Ruhe, also the author of two books on meditation and a teacher of university-level courses on Buddhist philosophy and meditation, emphasizes that the medicinal aspect is key. “You should avoid recreational marijuana, to avoid deluding thoughts.”
Sean Hillman, a Buddhist scholar-practitioner and a University of Toronto doctoral student in Religion, Bioethics and South Asian Studies, says that “it is difficult to establish an authoritative stance” on many issues.
As such, “what people choose to ingest is their private business, not subject to Buddhist religious scrutiny,” Hillman notes.
He spent 13 years as a Buddhist monk, ordained by the Dalai Lama. His research straddles religious studies and medical anthropology, with a strong interest in the interaction between religion and end-of-life decision making.
“Simply, when the pain at hand is addressed without any intoxicating side effects, medication has been administered correctly and pain management is effective,” he states.
“Finding the best delivery method and dosage are the challenges. If there is intolerable pain, it is not yet managed. Going beyond this threshold can lead to side effects, including drowsiness and even respiratory failure. I would ask if it is possible to treat illness by this means without side effects.”
The real challenge, therefore, may not be inherent in the chemistry of the drug. Unwieldy side effects are “obstacles on the various Buddhist paths,” as Hillman puts it.
Ajahn Punnadhammo, a Buddhist monk ordained in Thailand in 1992 who runs the Abbot of Arrow River Forest Hermitage in the Thunder Bay, Ontario, region, says most Buddhists would find medical marijuana acceptable because the use of opiates as painkillers for severe injury or illness has already been around for decades and Buddhists don’t oppose that medicine.
“Recognizing that any of these substances are open to abuse, most Buddhists would accept their proper medical use with due caution,” Punnadhammo adds.
==
How do Buddhists view medical marijuana?
The Medical Marijuana Review
Posted on January 2, 2014 by Dave Gordon in Feature Story
http://medireview.com/2014/01/how-do-buddhists-view-medical-marijuana/#.UuffYxb0DUT
Primary to the debate is what Buddhism calls the “five precepts”: refrain from taking life, don’t take what’s not yours, avoid sexual misconduct, don’t speak falsehoods, and avoid intoxicants.
It’s the last precept that’s a sticking point when it comes to medical marijuana.
Rev. Dr. Bhante Saranapala, a Buddhist monk and preacher working at the West End Buddhist Temple and Meditation Centre in Mississauga, Ontario, contends that the fifth precept forbids marijuana in any form.
“The five precepts are moral principles, and one of them is to refrain from intoxicants. If any substance leads to heedlessness, or could make one unconscious, you have to refrain, regardless of whether you think it’s good,” he says. “It alters the pure nature of the mind.”
The possibility exists, he added, that “you would not understand what you’re doing, or what you’re saying (while high). That’s why this is distinct.”
Historically there are few, if any, references in Buddhism regarding marijuana as a medicine, according to an article on Beliefnet.com.
Yet, the San Francisco Patient and Resource Center notes that Buddhists have used cannabis in tandem with meditation practices “as a means to stop the mind and enter into a state of profound stillness, also called Samadhi.” They add: “Various spiritual texts, including the Buddhist Tara Tantra, list cannabis as an important aide [sic] to meditation and spiritual practice.”
One source notes that Buddha himself believed cannabis was a cure for rheumatism.
Brian Ruhe, of the Theravada Buddhist Community of Vancouver, sides with the Dalai Lama on the issue.
“I’m in favor of [medical marijuana] as well. I explain it by saying the idea of medical marijuana is reducing suffering, and reducing suffering is good. In this case it’s reasonable, showing intelligent use for that situation,” he adds.
Ruhe has been a practicing Buddhist for 22 years and spent seven months as a Buddhist monk in Thailand in 1996.
“Medical marijuana is OK because Buddhism is a path of intelligence, discernment and compassion, not just following rules,” he contends.
“The Buddha said his teachings were not internally inconsistent because sometimes he would say one thing to a person, and something else to someone else. This is an example.”
Ruhe, also the author of two books on meditation and a teacher of university-level courses on Buddhist philosophy and meditation, emphasizes that the medicinal aspect is key. “You should avoid recreational marijuana, to avoid deluding thoughts.”
Sean Hillman, a Buddhist scholar-practitioner and a University of Toronto doctoral student in Religion, Bioethics and South Asian Studies, says that “it is difficult to establish an authoritative stance” on many issues.
As such, “what people choose to ingest is their private business, not subject to Buddhist religious scrutiny,” Hillman notes.
He spent 13 years as a Buddhist monk, ordained by the Dalai Lama. His research straddles religious studies and medical anthropology, with a strong interest in the interaction between religion and end-of-life decision making.
“Simply, when the pain at hand is addressed without any intoxicating side effects, medication has been administered correctly and pain management is effective,” he states.
“Finding the best delivery method and dosage are the challenges. If there is intolerable pain, it is not yet managed. Going beyond this threshold can lead to side effects, including drowsiness and even respiratory failure. I would ask if it is possible to treat illness by this means without side effects.”
The real challenge, therefore, may not be inherent in the chemistry of the drug. Unwieldy side effects are “obstacles on the various Buddhist paths,” as Hillman puts it.
Ajahn Punnadhammo, a Buddhist monk ordained in Thailand in 1992 who runs the Abbot of Arrow River Forest Hermitage in the Thunder Bay, Ontario, region, says most Buddhists would find medical marijuana acceptable because the use of opiates as painkillers for severe injury or illness has already been around for decades and Buddhists don’t oppose that medicine.
“Recognizing that any of these substances are open to abuse, most Buddhists would accept their proper medical use with due caution,” Punnadhammo adds.
==
How do Buddhists view medical marijuana?
The Medical Marijuana Review
Posted on January 2, 2014 by Dave Gordon in Feature Story
http://medireview.com/2014/01/how-do-buddhists-view-medical-marijuana/#.UuffYxb0DUT
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Monday, May 6, 2013
Fair Distribution in Jain Monastic Food Acquisition
Sean Hillman B.A., M.A.
Doctoral student, Religion/Bioethics/South Asian Studies
Department for the Study of Religion
Joint Centre for Bioethics
Centre for South Asian Studies
University of Toronto
This paper began as a textual investigation into the normative
prescriptions on the procurement and eating of food in three Indic monastic
codes of discipline: the Jain Ākāraṅga Sūtra, the
Pali Buddhist Vinaya, and the Swaminarayan-Vaishnava Shikshapatri
Bhashya. However, as the research unfolded, it became clear that there was
far too much material in these three codes, and their commentaries, for a paper
of this size. As such, the focus will be squarely on Jain monastic food orthodoxy
as found in a close reading of two primary texts that have ascetics as their
main intended audience: the Ākāraṅga Sūtra and Ācārya
Amitagati's Yogasāra-prābhṛta (Gift of the Essence of Yoga). The latter
includes a contemporary commentary by the translator Dr. C.S. Jain. Along with a
textual analysis of the primary texts, some ethnographic sources will help
demonstrate if contemporary Jain food orthopraxy is in agreement or at odds
with the orthodoxy of the texts.
There are endless discussions about what Jains normatively can and
cannot, and descriptively do and do not, eat. The forbidden foods, and proper ways
of preparing and eating food, are well documented. The central issue I chose to
explore within this paper, however, is the doctrinal restrictions related to
the procurement of food and drink by Jain monastics. As such, the scope
of the study was initially narrowed down to two main questions: (1) Under which
circumstances can the Jain monastic receive and not receive food? And, (2) From
whom can the Jain monastic receive and not receive food? I also began to comb
the texts to discover whether Jain monastics can ask for food verbally
or indicate hunger by physical gestures. Again, there was an
overabundance of material. These removed sections will be grist for a future
study.
I aim to demonstrate that the Ākāraṅga Sūtra contains
a more subtle approach to non-violence (ahimsa) than by way of mere
restrictions that are meant to protect humans, animals, insects, plants,
microscopic organisms and elemental beings from physical harm and that which
threatens life. Unlike the Yogasāra-prābhṛta, the author(s) and
redactors of the Ākāraṅga Sūtra are
proponents of the fair distribution of resources, demonstrated by
numerous precepts designed to protect donors, other Jain monastic and non-Jain alms
recipients from resource deprivation by requiring the monastic to not divert
food to themselves that would otherwise rightly go to another.
The Texts
The Ākāraṅga Sūtra and Yogasāra-prābhṛta
generally frame the usage of food quite differently. In the initial section
of the former, we find food consumption normalized: “As the nature of this
(i.e. men) is to be born and to grow old, so is the nature of that (i.e.
plants) to be born and to grow old…as this needs food, so that needs food”
(Jacobi 10). In the latter, engagement with food is villainized: “A yogī,
established in detachment, does not entangle (himself) in the obstructions
caused by…the food… For one indulging with indolence in activities like taking food…continued
violence has been described” (vs. 14-15 Jain 2003, 175-176) Despite such
disagreements, both texts give guidance to the Jain monastic on how to properly
acquire food.
My choice of the Ākāraṅga Sūtra is
based on the primacy given to it as a monastic discipline text in the Jain
traditions. It is “[t]he first Aṅga” or ‘limb’ from among the eleven still
extant (out of the original twelve) (Jaini 52) and is “appropriately called Āckāra
(Conduct), [as it] forms the law book for Jaina monks and nuns. It regulates
their conduct by delineating the obligatory vows…and also by giving specific
instructions pertaining to permissible methods for obtaining such requisites as
food, clothing, lodging, and medicine” (Jaini 52-53). Relevant to an
investigation into textual Jain monastic food regulations, it is also a text that
includes both monks and nuns in its discussions. Two sections are of greatest
relevance to our topic: the first book’s seventh lecture on ‘Liberation,’ and
the second book’s first lecture on ‘Begging of Food,’ with a heavier emphasis
on the latter. As for the Yogasāra-prābhṛta, I find the text quite
compelling despite several difficulties including the fact that it was written
exclusively for male monastics to the complete neglect of nuns. Jain’s
translation and annotations are also fraught with constant grammar and spelling
errors, and his commentary is only distinguished by paragraph indentations
rather than more typical and obvious markers (explicit mention of a
commentarial section, font changes etc.) He also adds words and phrases to the
root text within parentheses, presumably to clarify the meaning, but does not
explicitly indicate that they are his additions. At times these additions seem
to be considerably and alarmingly interpretive.
The most concerning feature of the Yogasāra-prābhṛta is the manner
in which it unabashedly deprecates females. I fear my potential for releasing a
tirade as my (albeit modern) feminist sensibilities are deeply offended, and cannot
restrain myself from at least briefly mentioning the misogyny of the author and
translator/commentator. Both writers hold that women have both physical and
mental obstacles that block them entirely from becoming liberated (Jain 187-189).
Amitagati lists seven problematic mental states that all women suffer from, ‘indolence’
being the main one which Jain unpacks as fifteen types of ‘psychoses.’ Next,
Amitagati tells the reader that certain parts of the female body are prone to
the “generation of subtle jīvas” (Jain 188) such as under the breasts,
in the armpits and genetalia. Due to this, he concludes that “the (necessary)
restraint is not possible in women” (Ibid.). I fail to see how this does not
similarly occur under the arms and genetalia of males, but there is no
symmetrical mention of this fact. Strangely, Amitagati then allows for women to
practice as monastics in the immediately following verse, and Jain assures us
that this can only at best lead to a male rebirth. Although men are not made
out in the text to be particularly prone to any mental or physical problems
based on gender, Jain attempts to temper his misogynistic position by stating
that “all male human beings are also not so qualified, as only a few of them
get liberation after undergoing the course of necessary discipline” (Jain 188).
It is also the position of many Jains that it is impossible for any human being
to become liberated in this age and our particular cosmographical location.
Regardless, the bias against females is undeniable and cannot be ignored.
As difficult as it is to suspend one’s disbelief in this matter, for this
paper the focus is on food regulations within a singular chapter in the Yogasāra-prābhṛta
that explicitly addresses monastic discipline, as the introduction states: “Chapter-8:
This chapter deals with the conduct of the truth seeker, which has to be
essentially observed by him” (Jain 2003, xvi).
Dating both texts is a difficult task. Starting with the Aṅga texts, the
Indian Historiographer Dr. Jyoti Prasad Jain suggests that those who would
become the Digambara began redacting and writing their canon around the end of
the first century B.C.E., “preserving the bulk of the twelfth Aṅga...together
with fragments from the other Aṅgas” (Jain 2006: 182), whereas those who
would become the Śvetāmbara resisted canonical writing until the late fifth
century C.E. They preserved “substantial parts of the remaining eleven Aṅgas”
(Ibid.). One might think that the Digambara emphasis on orthopraxic
discipline would mean that they would be intent on preserving the Ākāraṅga Sūtra, but the evidence as to when and which sect wrote the first Aṅga seems lacking. A wide window of time, no doubt, we can at best say it is from the late urban/early classical period with the lower limit of its composition as first century B.C.E. and sometime after the late fifth century C.E as its upper limit.
Locating Ācārya Amitagati's Yogasāra-prābhṛta
temporally is made difficult by the fact that there are two Jain scholar-monks
by the same name, and that our author “has not mentioned the date of the
composition of his work” (Jain 2003, xiii). The one indicator that remains is
that one of the two Ācāryas mentions the other: “Amitagati-II has immensely
praised Amitagati-I, in his work, Śubhāṣita-Ratna-Sandoha, which was
composed by the latter in the tenth century A.D. when Muñja was in throne”
(Jain 2003, xiii). The Encyclopaedia of the Hindu World describes this Amitagati as a “Sanskrit poet, who was a Digambara Jain ascetic and pupil of Mādhavasena. He is the author of the Subhāṣitaratnasandoha ‘Collection of Jewels of Happy Sayings’ (A.D. 1014)” (Gar 384). The dates given have a discrepancy of a century. Sen’s Ancient Indian History and Civilization confirms the reign of the Paramara King Munja as “between A.D. 970 and 973” (319). This still doesn’t tell us which period is correct in placing the text that retroactively mentions our Amitagati. Is Jain’s suggestion more accurate because he has a dynastic reference? It is unclear. We can say at best say it is an early medieval text composed sometime around or before the cusp of the tenth and eleventh centuries C.E.
Jain Monastic
Food Acquisition
In discussing Jain
food pujas, Indologist John E. Cort states that “[f]ood is necessary to
maintain the physical body which is both an obstacle to liberation and a symbol
of bondage… food is part of the physical fuel that drives the round of rebirth”
(2001: 78). Immediately we can see an inherent tension in the life of a Jain
monastic: dependence on food for survival prevents liberation. This is because
Jains hold that every single action and interaction, physical, verbal
and mental, causes some relative degree of harm to others and oneself
and thus binds the subtle substance of karma to the soul, especially the
interactions involved with procuring and consuming food since “[f]ood fuels the
calamity of bodily existence, and is also associated with the sins inevitably
occasioned by its production and preparation” (Cort 1998: 158). Cort also states that “[b]ecause of the spiritual hazards of eating, fasting is
central to both lay and monastic practice among Jains” (Ibid. 152). As such, Jain monastics aim to eventually quit the desire for, and eating
of, food altogether with ritual/voluntary fasting unto death (sallekhana),
a feat that we might call the ultimate austerity. Among the Jains I have
encountered, sallekhana is held in the highest of esteem by monastics
and lay-people alike and those who do and have done the practice are publicly revered with
great pageantry during the event, and with shrines and glowing storytelling
post-mortem. There are monastics still engaging in the practice today and
although theoretically possible for lay-people, their engagement in sallekhana
is quite a rare occurrence. Most will expressly hope to be able to perform the
ritual sometime in this or in future lives. Eating and drinking, as the most
important of the physical needs, are also the most difficult to renounce. To
stop the influx of karma, throughout their religious career Jain monastics
train for total mental equanimity and inaction in many ways, including
restricting the frequency of eating and types of foods consumed, and various
lengths of fasting. With these aims, and in relation to procuring the food and
drink necessary for “keeping the body going while on the road to liberation” (Cort 1998: 158), monastic texts and practice serve to minimize the negative results
of physical, verbal and mental actions through prescription
and proscription. Although not perfectly avoiding all activity, such
regulations ensure “[t]he mendicant recipient is protected by asceticism”
(Ibid.).
There is some variation in the sources as to the manner and frequency that
Jain monastics go out to beg for, or receive, food. With regard to this, the late German Indologist Hermann Georg Jacobi references the Kalpa Sūtra: “The Gaina monks
collect food in the morning or at noon … They generally but once in a
day go out begging; but one who has fasted for more than one day may go a
begging twice a day (f7. Kalpa Sūtra, Rules for Yatis, 20)”
(xxv). In contemporary practice, variation in the way of, and the number
of sessions for, receiving food seems to be based on sectarian differences. In
brief, Cort found that “[t]he Mūrtipūjak [Śvetāmbar] procedure of gocarī contrasts sharply with the much more formally ritualized
practice of āhār-dān or gifting of food among the
Digambar Jains,” (Cort 2001: 107) where some monastics in the former sect
collect on behalf of fellow monastics and request alms with a verbal cue, and
the latter sect only ever collect their own alms and indicate hunger by a mere physical
gesture. British Historian William Dalrymple noted that his monastic
informant “Prasannamati Mataji
belonged to the order of “white-clad Digambara nuns, or matajis” (2). Of the two major Jain sects, the Digambara are renowned for their strict religious life: “probably the most severe of
all India ’s ascetics” (Ibid.). As such, this nun reported that during her ordination ceremony her Guru “told us clearly what was
expected of us…to take food only once a day” (21) and that “[f]or many years, I
fasted, or ate at most only once a day” (4). It was also
observed that “[a]t ten o’clock each day, Prasannamati Mataji eats her one daily meal (11). Cort
observed a different approach among Śvetāmbar Jain monastics, who received food
three times daily: “Late morning is time for another food-gathering
round… Late afternoon is the time for the final food-gathering round and meal,
eaten before sunset (2001: 103). That there is no discernable pan-Jain
standardized requirement as to the number of alms-rounds will not at all hinder
this investigation.
We will next proceed to fair distribution in Jain
monastic food acquisition in two thematic sections: (1) not taking the
food of others while receiving food; (2) not taking the food
of fellow monastics after receiving food on their behalf.
Not Taking
the Food of Others While Receiving Food
The Ākāraṅga Sūtra holds the
resources of others as deeply valuable, and deploys an impressive number of
strategies to protect them from going to Jain monastics inappropriately. The
monastic is told to avoid public celebrations that offer food since “[w]hen a man goes to a much-frequented and vulgar entertainment…he
receives what should be given to others” (vs 4 Jacobi 95-96). There is also
one verse which shows a specific concern for ensuring that the Jain monastic
does not divert resources earmarked for the householder themselves: “there are some faithful householders …who will speak thus:… let us give to
the ascetics all food…that is ready for our use, and let us, afterwards,
prepare food for our own use.’ Having heard such talk, the mendicant should not
accept such-like food” (vs. 1 Jacobi 111). Monastics are also not to go
on alms-round to homes while food is being prepared:
A monk or a nun desirous to enter the abode of a
householder, should not do so, when they see that the milch cows are being
milked, or the food…is being cooked, and that it is not yet distributed. Perceiving
this, they should step apart and stay where no people pass or see them. But
when they conceive that the milch cows are milked, the dinner prepared and
distributed, then they may circumspectly enter or leave the householder's abode
for the sake of alms. (vs. 3 Jacobi 98)
This verse appears
to serve a dual purpose. Like the previous example, we see here another effort
to not lead the devoted Jain layperson to give what has already been portioned
off for their personal use. Additionally, following this precept is an attempt
to uphold another major requirement of Jain food orthodoxy and orthopraxy:
ensuring that no food has been prepared specifically for the monastic,
as this would directly implicate them in the karmic accumulation from any harms
done to living beings during such preparation. Anne Vallely, an anthropologist
of South Asian religions with a particular focus on Jainism, found this in the
contemporary practice of Jain nuns who informed her that “food must never have
been prepared expressly for them” (Vallely 3).
Another intriguing verse offers a special scenario:
If a householder
should fetch fossil salt or sea salt, put it in a bowl and return with it, a
monk or a nun on a begging-tour should not accept it… But if he has
inadvertently accepted it, he should return with it to the householder, if he
is not yet too far away, and say, after consideration: ‘Did you give me this
with your full knowledge or without it?' He might answer: 'I did give it
without my full knowledge; but indeed, O long-lived one! I now give it you;
consume it or divide it (with others)!' Then being permitted by, and having
received it from, the householder, he should circumspectly eat it or drink it (vs.
7 Jacobi 116).
Such food items are worrisome possibly because they are rare and costly.
First and foremost, our authors attempt to ensure that a householder does not
mistakenly give something that they either do not wish to give, or are in need
of for themselves. Checking with the donor is out of respect for both of these
possible valid reasons for not giving them. They are not made to be forbidden
items, but must be eaten clandestinely presumably so others do not see a
monastic taking precious food which would be considered unseemly by some and
harm the reputation of the order.
There are many verses, indicating a much greater textual concern,
which aim to ensure that the Jain monastic does not divert resources from
others who similarly rely on donated food, including non-Jains. Five of these
are explicit about avoiding this. One is generic: “A monk or a nun on a
begging-tour should not accept food…which for the sake of another has been put
before the door” (vs. 7 Jacobi 113). Two mention particular recipient-types;
one of which is found in the concluding lines of the begging of alms lecture: “the seventh rule for begging food. A monk or a nun may accept food…which is
not wanted by bipeds, quadrupeds, Sramanas, Brahmanas, guests, paupers, and
beggars” (vs. 9 Jacobi 118); and the other is the first mention of five recipient-types
that are given great importance by the text: “A monk or a nun
should not accept of food …which they know has been prepared by the householder
for the sake of many Sramanas and Brāhmanas, guests,
paupers, and beggars” (vs. 12 Jacobi 91). Next: “When a monk or a nun on a
begging-tour knows that a Sramana or Brāhmana, a guest, pauper
or beggar has already entered (the house), they should not stand in their sight
or opposite the door. The Kevalin says: This is the reason: Another, on seeing
him, might procure and give him food” (vs. 5 Jacobi 101). Lastly: “When a monk
or a nun on a begging-tour perceives that a Sramana or Brāhmana, a beggar or guest has already entered the house, they should not overtake
them and address (the householder) first” (vs. 6 Jacobi 102). The presence of
“Sramanas and Brāhmanas, guests, paupers, and beggars” at
food-related events is a frequently repeated refrain to continually reinforce
the concern of not taking the due share of these others and to cover various
possible scenarios, such as with the following: when such folk “are entertained
with food” (vs.1, Jacobi 92); during “assemblies, or during offerings to the
manes, or on a festival… when on such-like various festivals” (vs.3, Jacobi
92-93) these people are given food, but the prohibition is waived if “all have
received their due share, and are enjoying their meal” (vs. 4 Jacobi 93); “a
wedding breakfast in the husband's house or in that of the bride's father” and
“a funeral dinner or to a family dinner where something is served up,” unless
no such people are there and, further, the waiving of this prohibition
“applies, according to the commentator, only to sick monks, or such as
can get nothing elsewhere” (vs. 2 Jacobi 98); when “the first portion of the meal
is being thrown away (f1: In honour of the gods) or thrown down, or taken away,
or distributed, or eaten, or put off, or has already been eaten or removed”
since such people may “go there in great
haste” (vs. 1 Jacobi 99). At first glance we might assume that these
restrictions are displaying a non-sectarian motivation. However, it is also
possible that such textual moves are intended to avoid the Jain monastic order
from gaining the reputation among the community-at-large and the others who
similarly rely on the kindness of others, including those of other sects, of
interfering with others’ alms.
The purpose of one
particular precept is not made explicitly clear but follows directly after a
verse that prevents the Jain monastic from diverting the due share of other
beggars, which might indicate that it, too, is for the same purpose. In this
case, however, the recipients are animal scavengers: “When a monk or a nun on a
begging-tour perceives that many hungry animals have met and come together in
search of food, e.g. those of the chicken-kind or those of the pig-kind, or
that crows have met and come together, where an offering is thrown on the
ground, they should, in case there be a byway, avoid them and not go on
straight” (vs.1 Jacobi 102-103). There is another verse in this lecture on
begging of food that recommends steering clear of animals, but has to do with
protecting the mendicant and other life from harm (vs.3, Jacobi 100). Based on
the context of the verse in question, and the unlikeliness that the monastic
would take up such food from the ground (since taking up food “placed on the
earth-body”( vs.4 Jacobi 106) is prohibited and the “monk or a nun may accept
food which had been taken up from the ground” only if “placed in a vessel or in
the hand” (vs. 8 Jacobi 118)), I conclude that the concern is not the taking
of such food by the monastic. In walking close to the animals, there is the
potential for them to scatter out of fear and lose the opportunity to partake
of the food. An even more nuanced possibility is that after scattering the
animals may very well return, as we all have observed in nature, but the
original and natural order of arrival to the food would be disturbed by the
monastic. A variation on the theme of not depriving others of what would be rightfully
theirs, this would be a very subtle approach to non-harm, indeed. There is
another verse that may depict a similar interest in the needs of animals: “A
monk or a nun on a begging-tour should not accept any such-like raw unmodified
substances as sugar-cane, which is full of holes, or withering or peeling off
or corroded by wolves” (vs. 12 Jacobi 110). Its contextual placement has more
to do with avoiding food items that are still growing or potentially teeming
with life, such as with tiny beings that take up residence or are born in the
small spaces within plant-life. Also, ideally the cane would not have been
procured specifically for the monastic. However remote, these points do not
eliminate the possibility of a multi-purposed verse interested in protecting
plants, plant-dwelling beings, and wildlife food sources.
Not Taking
the Food of Fellow Monastics Having Received Food on their Behalf
While researching Jain ritual/voluntary death (sallekhana) in India in the summer of 2010, many of my interlocutors informed me that a
Jain monastic is not an appropriate person to be the donor of any items because
of their adherence to non-possession (aparigraha). As such, “the mendicant is dependent upon the laity for food and all the other
necessities of life” (Cort 2001: 105). Such ethnographic accounts might lead us to believe that Jain
monastics do not give food to other monastics but there are both textual and
anthropological evidence that show certain circumstances whereby the Jain
monastics distribute food to other monastics. Our two texts disagree as
to whether a monastic can give away food that has been given to them. Verse 64
of the Yogasāra-prābhṛta states: “The morsel of food placed in the hand
(of a saint) is not fit to be given to any other (person) (by the saint). If it
is given so, the saint should not take food (thereafter). If he takes (food)
(even then), the saint commits blemish (for himself)” (Jain 2003, 194). Jain
adds in his commentary that “[t]he saint must partake of food as offered by the
householder… He must not meddle with it or spare it for use by others. This
rule should be observed very strictly by him or he will incur sin for himself” (Jain
2003, 194). The verse taken alone does seem to allow for the monastic to give
away food that has been given to them, under the requirement that they do not
eat any more. I assume this to mean during that session of eating, and not
forever and always. A negative karmic result is said only to come if, having
given food away, the mendicant eats again and not by the mere act of giving
food away. The commentary has a stricter position than the verse. It does not
allow for the food to be given to another as the negative karmic consequence
comes from any act other than partaking of the food as it is. The commentary
also seems to suggest that the food offered must be eaten in its entirety and
not altered, such as with making small piles with the fingers to more easily
place food in the mouth.
Although there is a verse
in the Ākāraṅga Sūtra that forbids monastics from giving
food to fellow monastics, it is only under very specific circumstances: “A monk or a nun on a begging-tour should not give, immediately or
mediately, food…to…a monk who avoids all forbidden food, to one who does not”
(vs.10 Jacobi 90). This prevents cross-contamination between those whose food practices
differ. Otherwise, there are many situations outlined where it is
permissible, and even required, to give food to fellow monastics (and even
non-Jains). We find the following admonishment in the “Begging of Food”
lecture of the Ākāraṅga Sūtra:
A monk or a nun, having received a more than sufficient
quantity of food, might reject (the superfluous part) without having considered
or consulted fellow-ascetics living in the neighbourhood, who follow the same
rules of conduct, are agreeable and not to be shunned; as this would be sinful,
they should not do so. Knowing this, they should go there and after consideration
say: 'O long-lived Sramanas! this food…is too much for me, eat it or drink it! After
these words the other might say: 'O long-lived Sramana! we shall eat or drink
as much of this food or drink as we require; or, we require the whole, we shall
eat or drink the whole.’ (Vs. 6 Jacobi 112-113)
Here, giving
leftover food to fellow Jain mendicants is made to be a requirement, with
the fault lying in not attempting to give the leftover food to
them. If we consider this verse and verse 64 from Amitagati’s text, the root
verses alone, it appears as though: (1) having leftovers is anticipated and a
faultless possible outcome, and (2) having such leftovers and giving them away
to another Jain monastic, after the mendicant themselves has completed eating
what they require, is also at least not a breach in conduct. The
chronologically later text has thus amended the earlier textual requirement to
seek an appropriate recipient of leftover food.
There is another verse in the same lecture of the Ākāraṅga Sūtra which shows the monastic as one who receives food and
distributes it to fellow Jain monastics:
A single mendicant,
having collected alms for many, might, without consulting his fellow-ascetics, give
them to those whom he list; as this would be sinful, he should not do so.
Taking the food, he should go there (where his teacher…is) and speak thus: 'O
long-lived Sramana! there are near or remote (spiritual) relations of mine…forsooth,
I shall give it them.’ The other may answer him: ‘Well now, indeed, O
long-lived one! give such a portion!' As much as the other commands, thus much
he should give; if the other commands the whole, he should give the whole ’ (Vs.
1 Jacobi 113).
Again we see a discrepancy between our two texts.
In this case, for fear of the mendicant making distribution decisions based on
attachment, they are required to consult their teacher for permission and
guidance. The texts suggests that the teacher may well answer agreeably
to the request, but leaves room for the teacher to suggest otherwise in the
service of fairness. This practice of collecting alms on behalf of other
monastics is supported in ethnographic accounts of contemporary Jain practice. As briefly mentioned earlier, in the Digambar āhār-dān food gifting “each mendicant, no matter how senior, performs his or her own
food-gathering round” (Cort 107), whereas Śvetāmbar monastics do collect on behalf of other monastics. In a section entitled The
Daily Routine of a [Śvetāmbar] Murtipujak
Mendicant under ‘Gifting’ (Cort 2001: 100), the ethnographer
describes how “some of the mendicants go to the nearby homes of Jain laity to
collect food and water in their wooden bowls, a ritualized action known as gocarī” (102) and, while doing so, “[h]ow much the mendicant takes depends upon
the number of mendicants for whom he or she is collecting food” (107). The
potential for favouritism mentioned in the Ākāraṅga Sūtra verse above is solved in contemporary Śvetāmbar
practice not by consultation with senior monastics but by equal distribution to
all mendicants (103).
The “scholiast says that [it] should only be resorted to under pressing
circumstances” (Jacobi 102), but the Ākāraṅga Sūtra text does have an allowance for the Jain monastic
to not only divide up donated food according to his best discretion, but also
to give to non-Jain beggars:
Another man may bring and
give him food…and say unto him : 'O long-lived Sramana! this food…has been
given for the sake of all of you; eat it or divide it among you.’ Having
silently accepted the gift, he might think: 'Well, this is just (enough) for
me!' As this would be sinful, he should not do so. Knowing this, he should join
the other beggars, and after consideration say unto them: ‘O long-lived
Sramana! this food…is given for the sake of all of you; eat it or divide it
among you.’ After these words another might answer him: ‘O long-lived Sramana!
distribute it yourself.’ Dividing the food…he should not (select) for himself
too great a portion, or the vegetables, or the conspicuous things, or the
savoury things, or the delicious things, or the nice things, or the big things;
but he should impartially divide it, not being eager or desirous or greedy or
covetous (of anything) (vs. 5, Jacobi 101-102).
Despite the scholiast offering
the escape clause that this applies only in times of dire need, it is an
impressive verse nonetheless. Firstly, giving food to a monastic under the same
rule is one thing, and our texts disagree (to some extent) as to the
appropriateness such a practice. Giving food to non-Jains, who may or may not
even be mendicants, is another matter entirely! It is surprising since many
verses allow the monastic only to “share with his
fellow-ascetics in the neighbourhood, who follow the same rules of conduct, are
agreeable, and not to be shunned” (vs. 7 Jacobi 116). The food is not only to be portioned out equally, but the recipient who has
the unusual charge of dividing up the food is asked to leave the worst for
themselves. There seems to be an internal contradiction in these final lines
since they both call for negative partiality, giving the best and leaving the
worst, as well as impartiality which would mean that every recipient would get
equal amounts of both the best and worst foods. Both principles are evident but
the competing injunctions for fair distribution and abandoning desire in this
excerpt seems to be won by the latter, if the word-count is any indication of
emphasis. A similar warning is given for ordinary circumstances as well: “A single mendicant, having
received some food, might eat what is good, and bring what is discoloured and
tasteless; as this would be sinful, he should not do so” (vs. 3 Jacobi 114). When
there is enough to distribute, eating before returning to the religious
community does not seem to be problematic, nor is the equal distribution of
portions mentioned here. Rather, the act of eating what is best and leaving the
dregs for fellow monastics is proscribed. The verse leaves room for two
possibilities: the recipient (a) eats the dregs themselves and leaves the best
for others, or (b) ensures that every monastic (including themselves) gets an equal amount of both the best and worst parts of the food.
Lastly we have two examples of monks concealing food by
various means in order to divert them for their own use. The first has the
recipient monastic disguising the food to deceive others as to its quality:
A single mendicant,
having collected agreeable food, might cover it with distasteful food,
thinking: 'The teacher or sub-teacher…seeing what I have received, might take
it himself; indeed, I shall not give anything to anybody!' As this would be
sinful, he should not do so.
Knowing this, he
should go there (where the other mendicants are), should put the vessel in his out-stretched
hand, show it (with the words): 'Ah, this! ah, this!’and hide nothing. (vs. 2
Jacobi 114)
Using the hermeneutics of suspicion we can surmise that this sleight of
hand was known to our author(s) in a historical context where living off of the
kindness of others, both by religious practitioners and ordinary folk, is a
long-standing practice. It likely did not arise out of pure imagination and
they hoped to nip this trick in the bud. What complicates this scenario is the
potential for the teacher to disregard the code and take the best for
themselves! Going by the spirit of the law, the authors might hope that the
teacher would follow the same repeated principle of not taking the best food. The
next and final example has mendicants giving food for the sake of fellow
mendicants who are sticken with illness via an intermediary monastic:
Some mendicants say
unto (others) who follow the same rules of conduct, or live in the same place,
or wander from village to village, if they have received agreeable food and
another mendicant falls sick: 'Take it! give it him! if the sick mendicant will
not eat it, thou mayst eat it.’ But he (who is ordered to bring the food)
thinking, ‘I shall eat it myself’ covers it and shows it (saying): ‘This is the
lump of food, it is rough to the taste, it is pungent, it is bitter, it is astringent,
it is sour, it is sweet; there is certainly nothing in it fit for a sick person.’
As this would be sinful, he should not do so. (vs. 1 Jacobi 116)
This is among the few concluding verses of the ‘Begging of Food’ lecture
and features the particularly despicable possibility of a monastic hiding food
items and lying about the nature of those items in order to eat
food meant for a sick mendicant. I think it is significant that this section of
the Ākāraṅga Sūtra ends on such
a note. It gives a special emphasis on ensuring a fair share of food for the
most vulnerable members of the Jain monastic order.
Conclusion
In discussing the relationship between Jain monastics and lay-people, the
Ākāraṅga Sūtra gives great value to the resources
of householders. It also holds fair distribution in esteem, in both the
contexts of Jain monastics among themselves and between Jain monastics and
others who depend on food donations, both of human and animal species. I
propose that this is a very subtle manner of practicing non-violence that comes
from a deep concern for the well-being and integrity of Jain ascetic
practitioners and those they come into contact with over the course of their
religious careers. Having pored over every verse related to the topic of food
in this text, the sheer quantity of verses that push for protection of the due
share of non-Jain dependents betrays an anxiety that likely has to do with
protecting the reputation of the Jain monastic community. This is also supported by the constant
mention of various activities that are ultimately allowable but which should be
done in secret rather than in full view of watching eyes. There is some
indication that the Ākāraṅga Sūtra considers the
reduction of desire in the monastic as a more weighty requirement than fair
distribution. As for the conduct chapter of Ācārya Amitagati’s Yogasāra-prābhṛta,
despite leaning away from the idea, it does leave room for the monastic to give
food to other monastics. A similar emphasis on fair distribution as we see in
the temporally earlier Ākāraṅga Sūtra is
entirely absent.
Citations
Cort,
John E. Open Boundaries: Jain Communities and Cultures in Indian
History (SUNY Series
in Hindu Studies). State University of New York Press, 1998.
Print.
__________.
Jains in the World: Religious Values and Ideology in India .
Oxford University
Press, 2001. Print.
Dalrymple, William. “The Nun’s Tale.” Nine Lives: In Search of the Sacred in Modern India . Bloomsbury (2009): 1-28. Print.
Gar, Gaṅgā Rām (Ed.). Encyclopaedia
of the Hindu World: Ak-Aq. New Delhi :
Ashok Kumar Mittar, 1992. Print.
Jain, Dr. C.S. (Tr. &
annotations); Ācārya Amitagati's Yogasāra-prābhṛta (Gift of the
Essence of Yoga). Bharatiya
Jnanpath, New Delhi ; 2003. Print.
Jain, Dr. Jyoti Prasad. Religion
and Culture of the Jains. New Delhi :
Bharatiya Jnanpith, 2006. Print.
Jaini, Padmanabh S. The Jaina Path of Purification.
Motilal Bariarsidass, 1998. Print.
Jacobi, Hermann (tr.). Jaina Sutras Part I: The Ākāraṅga
Sūtra, The Kalpa Sūtra. Oxford University Press, 1884. Motilal Bariarsidass, 1964. Print.
Sen, Sailendra Nath. Ancient
Indian History and Civilization: 2nd Edition. New
Delhi : New Age International
Publishers, 1999. Print.
Vallely, Anne. Women and the Ascetic Ideal in Jainism.
Doctoral Dissertation, Department of Anthropology: University
of Toronto ,1999.
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