Tag Archives: consent

Expertise, politics of health and the Doctor as an Educator

This post is culled from an exchange in a medical group I am a member of. Mr. Srivats has kindly granted my permission to reproduce this gem of a letter. Pay particular attention to the last 3 paragraphs.

Dear Friends,

As I promised in my previous mail, I am adding to the question of the relation between expertise and the politics of health care based on the progression of the Gentamycin – Co-trimoxazole debate. I would remind those who don’t know me, that I am not a doctor, I have little knowledge about these drugs, or drugs in general, and my intervention is related to precisely how to negotiate expert knowledge and a democratic form of medicine.

The specific case here is the exchange between Drs. Sri and S about the pros and cons of discussing such a complex issue in a public forum. On the one hand, I am able to see entirely the validity of Dr. S’s concern that imprecise knowledge and opinions can result in confusion, especially in a multilayered group like the xx egroup. On the other hand, it is precisely the question of expertise and the need to give direction without causing confusion that runs against the problem of a democratic medicine. Should we prevent confusion? Yes, if possible. Should we discuss the matter openly with a group that doesn’t have expertise in the matter — Yes, certainly. Whether it is the case of medical intervention for babies or nuclear power at Koodankulam (I am taking this comparison because of the expert dimension and impact on populations here too), the answer has to remain positive. How do we resolve this dilemma? Not only at the level of health care professionals, but also at the level of patients and communities.

This is where I feel that the position of the doctor as an educator must be examined. Do we have general discussions with parents and the community about giving injections to new-born children? Or oral medication? They certainly won’t have any expertise but they will know what the baby is actually going through on a 24×7 basis. I also have it on some authority that in the rural areas and perhaps among the poor in general, injections are a sign of a ‘good doctor’. It is therefore likely that they would welcome injections for their children without in any way of knowing about the risks and consequences. But I feel since the risk is theirs — their children’s lives to be precise — they should know, confusing or not. I will stress here that there is no point in romanticizing the people in the neoliberal mode — ‘people know best and they must make an informed consent’ — as we all know from the clinical trials scenario, informed consent is a travesty of the right to know what is being done to your body. Yet, I can’t help feeling a discussion must begin, with a democratic education and consciousness raising practice among committed medical professionals. I hope this doesn’t sound like preaching — it is more an exploration of possible avenues for a critical medical practice.

About toxicity and side effects too. This is a general aspect of medical care in its history — the positive iatrogenic effects of medicine (i.e. not the failures of medicine due to bad practice) but the costs of the successes of medicine in patients lives and health over generations of research, shots in the dark, and development. In the final analysis it simply isn’t enough for the doctor to decide that a particular percentage is below the threshold of significance and that therefore the particular medicine can be treated as safe. How can a democratic medicine begin to function in such a way that people know about the risks they take. And yet, I am aware that the general consensus (and medical science’s opinion) is that such an approach is impossible, but isn’t such a conversation imaginable (at the simplest, individual level, and at a much more sophisticated community level): ‘One in ten thousand babies who are given this medicine die, however, it is also documented that the following benefits do occur to the majority who are given it — do you want to take the risk?” to which the parent replies “No” or “Ok, Inshallah!”

It is perhaps likely that doctors who ask these questions will lose their practice to the confident practitioner who simply goes ahead and gives the injection or the tablet — but that raises another problem. How do we educate people out of this blind faith in the expert? The question is how to make the engagement with the doctor a face to face encounter, rather than one of command and obedience.

Would the members of xx feel it is necessary to pioneer this difficult political practice of a critical democratization of expertise? Not in the sense of making everybody technologically equal, but in the sense of teaching people to think about a decision making process on an issue that has bearing on their infants’ mortality (or any such issue of medical care)?

R Srivatsan
Senior Fellow
Anveshi Research Centre for Women’s Studies

The Cathartist replies to Pervocracy on Consent culture

Molly, the author of Pervocracy a fantastic blog about sex, BDSM, and feminism, featured Consent Culture recently. She talks about how consent is the standard/default behavior we need to work towards. The post is thought provoking. While we know that consent is a great way to equalize the sex equation, we still havent found ways on how to get consent into daily lives. She suggests some ways this can be done.

The Cathartist, a friend and editor of Gaysi: the Gay Desi responds to some of the suggestions and ideas put forward in the post.

 

A consent culture is one in which the prevailing narrative of sex–in fact, of human interaction–is centered around mutual consent. It is a culture with an abhorrence of forcing anyone into anything, a respect for the absolute necessity of bodily autonomy, a culture that believes that a person is always the best judge of their own wants and needs.

I am totally down with the necessity of absolute consent when speaking in context of sex. However, when the blogger (from now on, P) talks about asking my partner, “Is it okay to hug you?”, I am not so sure about such absolutes. In a separate context, I also don’t believe that every person is always the best judge of their own wants and needs. I’ll illustrate why, further down the article.

I don’t want to limit it to sex. A consent culture is one in which mutual consent is part of social life as well. Don’t want to talk to someone? You don’t have to. Don’t want a hug? That’s okay, no hug then. Don’t want to try the fish? That’s fine. (As someone with weird food aversions, I have a special hatred for “just taste a little!”) Don’t want to be tickled or noogied? Then it’s not funny to chase you down and do it anyway.

I can think of plenty of situations when a close friend or parent saw I needed a hug and gave me one. I felt comforted in the knowledge that they knew when I was down and out even without me having to express it in so many words. A few years ago, I got into a fight with a friend because I refused to eat the carrots that our host had prepared so lovingly. He thought I was being rude. Look, I have food aversions, but I see why people say, ‘try just a little’. It  actually feels irrational to dislike food that you’ve never eaten before. Especially when the person offering is so convinced of its deliciousness or perhaps have cooked it themselves. I am not saying you should ABSOLUTELY try it. I am just saying, it’s okay for them to be a little persuasive and it’s okay for you to say, “no”. No one says, “Yes, please. I’d like a tickle now.” It’s one of those weird human sensations that makes you giggle and laugh hysterically but you want to resist every time someone tries.
I wouldn’t want a stranger tickling me. But if my sister did, I’d be okay with it. Much of my disagreement with this article is that EVERYONE (strangers, lovers, friends, colleagues, parents, children, neighbours) is considered “the other” who must grant or request consent. We share different levels of intimacy with different people. And in the specific relationship between parents and children, I do wish my parents had forced me to train for a few sports. And I am grateful that they forced me to learn music and dance. As a 5 or 6 year old, a child may have no idea if he or she wants to grow up to be a pianist or if they would enjoy tennis. They might share a classmate’s chocolate milk and decide that they want to have it every day, all the time. That is the child’s wish. Should my parents concede to it? Should parents negotiate with the children? Maybe.

Consent has its place, no doubt. Establishing personal boundaries and space is important. But there are no absolutes as P’s description of consent culture outlines.

5. Ask before touching people. Say “do you want a hug?” and if they say no then don’t hug them–and also don’t give them any shit about not being friendly or affectionate. Don’t make a big deal out of it, just make it part of your touching-people procedure. If they say “you don’t need to ask!” nod and smile and keep on asking.

See, this is a fine example of the need to make distinctions between the different circles of people in your life. Different cultures world over have different boundaries in the context of physical intimacy. Just today, I was asked by yet another American about Indian men who hold hands. She found it strange, she said, that heterosexual men share that level of physical intimacy.

I am sure, my very young cousins would look at me quizzically if I asked, if I could hug them. I would also not expect that they ask me, before they slathered my face with a lot of kisses. I think P touches on this slightly, when she talks about renegotiating sex in the context of long-term relationships. But even among friends, sometimes, the best part of knowing someone for a long time, is the unspoken communication. Knowing when to keep quiet and knowing when to give advice. Knowing when to hug and knowing when not to. It is okay to take that for granted.

I would find it very caring and considerate if a new partner would ask me “Is it okay to do this?” or “Does it hurt when we do this?”. But I would find it annoying if s/he asked me that EVERYTIME. There are situations, where such consent is unnecessary.

11. Bring consent out of the bedroom.  I think part of the reason we have trouble drawing the line “it’s not okay to force someone into sexual activity” is that in many ways, forcing people to do things is part of our culture in general. Cut that shit out of your life. If someone doesn’t want to go to a party, try a new food, get up and dance, make small talk at the lunchtable–that’s their right. Stop the “aww c’mon” and “just this once” and the games where you playfully force someone to play along. Accept that no means no–all the time.

I am sure, I would’nt have tried half the things in my life, if I hadn’t been persuaded by a parent or friend or sibling. Like that time I went on a roller coaster. Or that time I went to a live concert on New Years’ Eve. I am not saying I have liked all my experiences. But I know for sure, that I dislike it for a certain reason. For example, Sushi. I don’t understand its wide spread appeal and I’ll never eat it again. But I tried, only because I was coaxed.

Beyond what’s necessary for their health and education (and even that touches iffy territory), I don’t believe in doing this to kids, either. The size and social-authority advantages an adult has over kids shouldn’t be used to force them to play games or accept hugs or go down the big slide. That sets a bad, scary precedent about the sort of thing it’s okay to use your advantages over someone for.

As a parent, it is a lot more easier to use one blanket rule because there is no grey; just black and white. “You ALWAYS ask for permission.” “You ALWAYS say no to a stranger”. This consent rule is exactly the same. It is okay to ask children to try new things. As children they are vulnerable and they look to parents to tell them what’s best for them. Of course, this depends on the situation. It is NOT okay to force children to accept hugs or wear clothes that they are not comfortable in. But it is okay to force kids to try their hand at Ludo or read a page of a story book. Sometimes, this “forcing” should be done through negotiations. My parents negotiated hair cuts (which I absolutely hated) by buying me a book for every time I had to do it.

My sister does not take enough care of herself when she’s in staying away from home. As a result, her health had suffered some consequences. When she visits, I push her to go visit a doc, spend some time on personal grooming. She’s about 23 and she has never done her brows. That’s her personal wish and I respect that. But I do insist on some hard-core heel sloughing and scrubbing and a real pedicure. And I know she wouldn’t have done it if I hadn’t insisted (out of sheer laziness). Am I taking personal liberties? Yes. But I come from a good place and I don’t believe I am doing her any harm.

 

For more of  The Cathartist, try  The guide to understanding lesbians Part 1, and part 2, a hilarious exchange she Broom, the co-founder of Gaysi, had with a prominent men’s magazine.