Bioethics for clinicians: 19. Hinduism and Sikhism
Harold Coward, Tejinder Sidhu

CMAJ 2000;163(9):1167-70

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Hindus and Sikhs constitute important minority communities in Canada. Although their cultural and religious traditions have profound differences, they both traditionally take a duty-based rather than rights-based approach to ethical decision-making. These traditions also share a belief in rebirth, a concept of karma (in which experiences in one life influence experiences in future lives), an emphasis on the value of purity, and a holistic view of the person that affirms the importance of family, culture, environment and the spiritual dimension of experience. Physicians with Hindu and Sikh patients need to be sensitive to and respectful of the diversity of their cultural and religious assumptions regarding human nature, purity, health and illness, life and death, and the status of the individual.

Mr. and Mrs. K, an orthodox Sikh couple, are happily anticipating the birth of their first child. The pregnancy is uneventful until 32 weeks, when gestational hypertension is diagnosed. Over the next 2 weeks Mrs. K's condition continues to deteriorate despite bed rest, hospital care and intensive medical management. Mr. and Mrs. K consent to cesarean section to save the lives of mother and child. At 34 weeks a female infant is delivered by cesarean section under general anesthetic. The baby is grossly edematous, looks dysmorphic and has an Apgar score of 1 at 1 minute. Her birth weight is 1000 g, and the placenta is small and calcified. Mrs. K is still under general anesthetic, and Mr. K is not in the operating room. The physicians need to decide on the degree of intervention. Fortunately, the infant responds to basic stimulation from towelling and drying under a prewarmed radiant heater and to resuscitation with oxygen by face mask. Her Apgar score is 6 at 5 minutes and 8 at 10 minutes. The baby is transferred to the neonatal intensive care unit, and a buccal smear is sent for karyotyping to rule out chromosomal abnormality. Following the surgery, the physicians meet with Mr. K to discuss the baby's condition. The neonatal specialist, considering the baby's condition to be grave and irremediable, advises against intensive intervention.

Hinduism is the most ancient religion of India, dating from about 2500 BC. Sikhism, which has influences from Hinduism, arose as a separate religion some 500 years ago. The majority of Sikhs live in the Punjab, whereas Hindus are found throughout India. The first wave of Sikh immigration to Canada occurred between 1905 and 1915 on the west coast; however, the majority of Sikhs came to Canada between 1960 and 1985. Hindus began immigrating to Canada in the 1960s.

In the Hindu and Sikh traditions, there is no great distinction between religion and culture, and ethical decisions are grounded in both religious beliefs and cultural values. In contrast to the contemporary secular approach to bioethics, which is predominantly rights based, Hindu and Sikh bioethics is primarily duty based. Indeed, there is no word for "rights" in traditional Hindu and Sikh languages. (Although most Sikhs speak Punjabi, Hindus speak a variety of languages, including Hindi, Bengali, Marathi, Tamil and Malayalam.) Traditional teachings deal with the duties of individuals and families to maintain a lifestyle conducive to physical and mental health. Although there are profound differences between the Hindu and Sikh religions and considerable diversity within them, these traditions share a culture and world view that includes ideas of karma and rebirth, collective versus individual identity, a strong emphasis on purity and a preference for sons.

The notion of karma and a belief in rebirth will be important for many Hindu and Sikh patients as they make ethical decisions surrounding birth and death. Unlike the linear view of life taken in Judaism, Christianity and Islam, for Hindus and Sikhs life, birth and death are repeated, for each person, in a continuous cycle. The fundamental idea is that each person is repeatedly reborn so that his or her soul may be purified and ultimately join the divine cosmic consciousness.¹ What a person does in each life influences the circumstances and predispositions experienced in future lives. In essence, every action or thought, whether good or evil, leaves a trace in the unconscious that is carried forward into the next life. When a similar situation is encountered, that memory trace arises in the consciousness as an impulse to perform an action or think a thought similar to the earlier one. This impulse does not necessarily compel the person to repeat the act or thought. He or she can still exercise free will by either nurturing or uprooting what has been laid down in the unconscious. Karma theory rejects any absolute beginning and assumes that life has always been going on. Consequently, each person is thought to have a huge store of memory traces from previous lives that are transferred at birth and that, with the additions and deletions made through free choice in the current life, will influence rebirth in the next life.² From this perspective, the moment of conception is the rebirth of a fully developed person who has lived many previous lives. Termination by abortion sends the soul back into the karmic cycle of rebirth.

Another major difference between Hindu and Sikh cultures and Western cultures concerns the question of identity. Who is the ethical agent in decision-making: the patient, or the family? In Western secular society the individual person is viewed as having autonomy in ethical decision-making. In Ayurveda (traditional South Asian medicine) the person is viewed as a combination of mind, soul and body in the context of family, culture and environment (nature).³ Thus, the person is seen not as autonomous but rather as intimately integrated with his or her extended family, caste and environment. This necessitates a holistic approach to ethical matters such as informed consent, one that includes the patient's societal context as well as the religious or spiritual dimension of his or her experience.

Purity is an important value in Hindu and Sikh culture.⁴ In the classical Indian tradition, there are 2 terms for "purity." Suddha (or shudh in Punjabi) evokes the image of the human body or elements of nature (e.g., the Ganges River) in their most pure, perfect and desired state of being. Sauca (sucha in Punjabi) also means "pure" but relates more specifically to personal cleanliness. The most impure (asauca, or jutha in Punjabi) substances are the discharges of one's body. Women, since they have more discharges (e.g., menstruation) than men, are seen as being more impure. Only before puberty or after menopause does a female approach the standard of purity of a male. The matter is even more complex because the purity–impurity axis in daily life is bisected by the auspicious–inauspicious axis (subha–asubha). For example, childbirth is auspicious if it occurs under the right circumstances. However, even if the circumstances are favourable, the act of childbirth itself, involving the discharge of bodily fluids, renders the mother impure. The baby is also impure, but this impurity becomes insignificant in view of the auspiciousness of birth, particularly the birth of a son, which is duly celebrated through ritual performance and social ceremonies during the following 11–13 days, culminating in the ritual of purification.⁵

There is a general bias in favour of males over females in Hindu and Sikh culture. The roots of this bias are 2-fold. In Hinduism, for example, the eldest son is required to light his father's funeral pyre and to perform yearly rituals for the well-being of the father in the next life. The eldest son is also the head of the extended family and has the responsibility to protect and provide for the women in the family; this includes a moral obligation to ensure that sexual mores are preserved. Sons at marriage receive a dowry with their wife, which adds to the family wealth. Daughters, in taking a dowry with them at marriage, do the reverse. The responsibility of eldest sons to provide for and protect the women in their extended families means that there is often a strong male dominance in matters of consent.

The ethical theories employed in health care today tend to apply a Western philosophical framework to issues such as abortion, euthanasia and informed consent. Yet the diversity of cultural and religious assumptions with respect to human nature, health and illness, life and death, and the status of the individual demands that physicians be sensitive to and respectful of the varied perspectives that patients bring to ethical decision-making.⁶ Hindus and Sikhs are important minority groups in Canada. Recent census figures show that about 500 000 South Asians, of whom Hindus and Sikhs make up the majority, are living in Canada, mainly in Montreal, Ottawa, Toronto, Winnipeg, Calgary, Edmonton, Vancouver and Victoria. There are more than 1 billion South Asians in the world population. Many Hindus and Sikhs in this country, especially second- and third-generation Canadians, have acculturated to the dominant rights-based approach of Western bioethcs, but recent immigrants, particularly older people, may apply the duty-based approach of their own tradition when considering treatment options.

To avoid miscommunication, physicians need to understand and respect the religious and cultural traditions of their Hindu and Sikh patients. They also need to recognize the diversity of beliefs and practices within these populations. Individual patients' reactions to a particular clinical situation will be influenced by a number of factors, including how recently they or their families arrived in Canada, their level of education, whether their roots are rural or urban, their socioeconomic status and their religious stance (e.g., fundamentalist v. moderate). Table 1 summarizes essential points to keep in mind when providing care to Hindu and Sikh patients.

Extended families are common and provide family members with social support and financial security. Tradition favours frequent visits to an ill person by friends and members of the extended family to offer support. Therefore, the physician may encounter more visitors at the patient's bedside than he or she is accustomed to. Elderly members of the extended family provide advice, help with child care and are accorded respect. The family spokesperson, with whom issues of consent will usually have to be negotiated, is usually the most financially established senior person in the family; however, if there is a language barrier, a younger member of the family may fulfill the communication role for the family.

If the patient and physician do not speak the same language, every effort should be made to find a trained and impartial interpreter who is familiar with the patient's traditions and culture. It is particularly important in issues of consent to ensure that information given to or received from the patient is not being censored or altered by the interpreter. Because of their deep sense of modesty and of purity, Hindu and Sikh women may not feel comfortable with male physicians or interpreters. Family members such as a teenaged daughter may function well as an interpreter for minor problems; however, an older, trained Hindu or Sikh woman who understands medical terminology and is not a family member will make the best interpreter, especially in urological and gynecological matters. In some circumstances a female relative or the patient's husband may have to serve as an interpreter, but, in view of the importance of preserving the confidentiality of the physician–patient relationship, using an interpreter who knows the patient personally is not the preferred approach.

The physician may need to alter his or her usual communication style in caring for Hindu and Sikh patients. By planning for a longer interview and adopting an indirect conversational approach, the physician is likely to learn more. It also helps to be alert to untranslatable Hindi or Punjabi words commonly used to express psychosomatic symptoms; for example, the phrase dil (heart) kirda (fragmenting) dubda (sinking), which an interpreter or the patient may express in English as "a sinking heart," implies tremendous anxiety that may result from a headache, nausea, stomach pain (especially epigastric) or generalized malaise. The physician should rule out organic disease before adopting a psychosomatic interpretation. He or she should also be alert for the term nazar ("evil eye") accompanied by a black mark behind the ear or a black thread around the wrist to protect the patient against the malevolent wishes of another. In many Hindu and Sikh households there is an attachment to traditional medicines (e.g., Ayurveda and Siddha), which may be used together with modern medicine.⁷ Cultural beliefs about health, disease and treatment often differ significantly from standard Western medical practice, and there are likely to be differing dietary practices as well, ranging from veganism (no meat, fish, eggs or dairy products) to a rejection of beef but acceptance of chicken or fish.

Case 1

Contrary to the physician's expectation, Mr. and Mrs. S do not wait for the counselling appointment but travel to the United States to have the pregnancy terminated.

For Hindus and Sikhs the single most important ethical consideration surrounding the start of life is their belief in karma: that the fetus is not developing into a person but, rather, is already a person from the moment of conception. Abortion at any stage of fetal development is thus judged to be murder. However, abortion is accepted by Hindus and Sikhs if essential to preserve the life of the mother.⁸ Furthermore, the religious prohibition of abortion is sometimes at odds with the cultural preference for sons. For Mr. and Mrs. S, the desire for a son outweighs the stance of their religion against abortion.

Case 2

Mr. K affirms his religious belief in the sanctity of life and insists on maximum medical intervention. Baby K's edema resolves by 50% over the next 24 hours and resolves completely by 72 hours. She requires minimal medical intervention and leaves the hospital at age 10 days. Karyotyping results are normal.

In this example, it might have been easy to allow the cultural bias against female babies to prevail. However, unlike in the first case, the parents' religious beliefs overruled their cultural biases — and the clinical and ethical judgement of the physician involved.

Competing interests: None declared.

Contributors: Each author contributed equally to the research for and writing of this paper.

Reprint requests to: Dr. Harold Coward, Director, Centre for Studies in Religion and Society, University of Victoria, SED B102, PO Box 1700, Station CSC, Victoria BC V8W 2Y2; fax 250 721-6234; csrs@uvic.ca

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