Shrink's Views

ramblings of an unknown psychiatrist

Archive for the ‘ethics’ Category

Two Ships: a painting

Posted by Dheeraj Kattula on December 4, 2011

Two Ships

Title:Two ships
Watercolour on Handmade paper
3.12.2011
Original Size:29 x 39 cm

This painting reminds me of something I had pondered over few years ago.
The main issues that a captain of the ship is concerned with are
1. How to keep my ship from sinking?
2. How to avoid bumping into other ships?

In life the answer to first question leads us to ‘personal ethics’. The answer to the second question leads us to ‘social ethics’.

Is not the problem of mankind beyond the pragmatic – why is the ship in the sea? 🙂

I had not removed the painting from the easel when it was done. As I kept looking at it, it looked a bit dull.So I added lemon yellow into horizon area, darkened the foreground waters,added some detail into the ship with ball point pen, added some background interest with birds and finally remembered to sign 🙂 Friends later pointed out that the version 1.0 had better reflections of the ships in water. I then added some plain water to the ships bottom parts and let the water drip to get the reflection look on to the painting. This is the final version of two ships.

Two Ships

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Love – Feeling, Reason and Choice: a story

Posted by Dheeraj Kattula on September 19, 2010

Background:

This is continuation of the story “Rights and Love”. If you have not read it, you could find it by clicking this. It was a story about a lawyer called James. His wife Agnes suffered with Schizophrenia. Under the influence of some delusions she attempted to murder him. He recovered and then took care of her. Despite all care she had not improved much. He continued to care for her despite the risk of harm that he could suffer. He surprised everyone with his love.

Love: feeling, reason and choice

It was nearly six months since Tab Clozapine was started. James reported that Agnes was doing well. She was not suspicious as before. She had started working again two weeks ago. She had put on some weight, but she got back the smile that she always had. As Agnes waited in the queue to get her medicines from the Pharmacy, James was called back by Dr Manas to the consultation room.

Dr Manas said “Mr James, I was glad to hear that Agnes is doing well. I wanted to tell you something. Do you have few minutes?” James was so happy that Agnes has improved so much. His eyes filled with tears as he said, “Of course doctor, you are always there for us. Please go ahead.”

“I have resigned my job here and I am moving to Kolkata. So I have transferred the care of Mrs Agnes to Dr Gurupreet Kaur. You have seen her during the in-patient stay. She is a fine doctor”, Dr Manas said as he looked away from James and stared into the empty sky through the window. He did not notice the crushed look on James’s face, as he nodded his head. James liked Dr Manas. He was a good doctor.

Suffering is not new to Dr Manas. He saw it every day. He was used to it. Despite his heroic efforts, his patients continue to succeed in suicidal attempts; they go off medications and relapse into full blown illness episodes. This was part of his life, but there was some suffering different about the case of Agnes and James that touched him.

“Mr James, I have seen many families with mental illness. They all care. If they did not care, the patients would not have been brought here or the family member would not have come here. I have seen people get beaten in episodes of rage. I have seen domestic violence exist in chronic form, but I have never seen one who had a brush with death because of an attempted homicide by a wife, care for his assaulter with so much of dedication and persistence. I admire you, Mr James. How do you do it? Is your marriage a love marriage?” Dr Manas inquired.

James smiled and replied, “I do not know if you could call it a love marriage. I guess you could. Agnes and I went to the same Church in Bangalore. Her parents had passed away in a road accident in her childhood. Her grandfather brought her up. He was a retired railway employee. They lived on his pension. He had multiple strokes and developed dementia. Agnes took good care of him. She used to bring him for the mass regularly. She was also active in the Sunday school.

I liked the way she behaved with children and elderly people. She was simple and had a simple lifestyle. I was interested in providing legal aid to poor people in Mumbai. I wanted to marry a girl who could fit in. I reasoned Agnes could be the right girl. I discussed this with the Church father. He was very happy. Agnes agreed to marry me. We got married after she finished her graduation. In the meantime her grandfather passed away. Then we moved to Mumbai.”

“Oh I see. Looks like you took a logical decision. Isn’t it?” Dr Manas asked.

James replied, “Yes sir. It was a 100% rational decision. I never had any flutter in my heart seeing Agnes nor did I miss sleep. In fact I have not had the feelings for Agnes that I once had for a girl…(smiles)

I had this feeling of being in love when I was in my 3rd year in the Law College. Permit me to leave her unnamed. She was the only daughter of a top criminal lawyer in Bangalore. She was obviously going to take over her father’s practice. Her father defends crimes done by politicians and their goons. She would have to do the same.

I desired a just society. If I married her, I would be aligning myself with enemies of truth and justice. I knew she was not the right girl for me.

Trust me; this knowledge did not help me lose feelings for her. I would get energized as if I had two cups of chai, if she were to just say a hello. I just cannot explain it. This ‘love’ seemed real, as I could feel it strongly. It lasted a year till she started going around with a minister’s son.” He smiled and added, “Thank God for that match! My emotions left. ”

“You said that you never had strong feelings for Agnes, but you seem to demonstrate love that I have not seen before. How is that?” Dr Manas asked inquisitively.

“Dr Manas, I have decided to love my wife Agnes. However she is, whatever she does, I will love her. I mean I would act in her interest. I might not have feelings like I had in college. I might not be as rational as when I had decided to marry Agnes. Love here is a choice I make.

In College years my feelings of love were not even in line with reason. They felt most real, but they were most deceptive. These feelings just evaporated. Imagine trusting those feelings and taking life decisions. My reason was stronger than my feeling when I decided to marry Agnes. If the situations did not change, reason would have been sufficient cause for a lasting marriage.

But things changed. You know it. I could have started a new life without her. Getting her out of prison and living with her in the same house with no one else, when she was still suspicious of me goes against sound reason. It was a choice I made to love Agnes that mattered. I thought in her interest. I had risk. I had fear. I faced it. It was ultimately a choice I made.”

“Mr James, I like the choice you made. I respect it. I appreciate it. In fact, you have inspired me to make such a choice. I normally don’t discuss my personal life with patients or their families, but I think you are different and I thought I could share this with you.

Let me first tell you that I hate Kolkata. I am a Bengali .I believe anyone who wants to work hard and grow cannot do so in Bengal. So, I always wanted to move out of Bengal.

I was involved in research which was being done in collaboration with the Indian Statistical Institute in Kolkata. I fell in love with a mathematician there. She was beautiful, brilliant and a Bengali. I had all reasons and all the feelings to get married. We married and were happy for few months. I then noticed that she was drawing closer and closer to her equations and was distancing herself from me. I do not suspect her for having an affair or any thing, but I felt she was not contributing to our relationship. I felt she was not valuing our relationship. Her equation was not an equality.

I got an opening here in Mumbai. I came here thinking that the distance would make her realize my absence and seek me. It did not work out. A couple of months ago I sent a divorce notice to her. Then I saw you. I saw what you were giving after having tasted what you had received. I knew this transcended reason and feelings. I thought I too should choose to love my wife.

Last month I called her and asked her forgiveness. I told her that though I hate Kolkata, I am willing to join her in Kolkata because I choose to love her. To my surprise, she wept. She felt sorry. She felt ashamed to call me and was desperately waiting for me to call. She too asked for my forgiveness as she had not been concerned for me.

She has requested a transfer to Indian Statistical Institute in Bangalore, with the idea that I can join NIMHANS. It is a matter of time that this would come through. I am glad I made the right choice. If I chose freedom as a right, we both would have lost. As I chose love, we both have gained.”

“I am so glad for you, sir. May God bless your marriage.” James blessed as a matter of fact.

Dr Manas held the hands of James and thanked him. Agnes came to the door after buying her medicines. They bid good bye to the doctor. Wiping his tears, the psychiatrist wondered when love as a choice is so beautiful and worthy, why we humans are so reluctant to choose it.

Posted in challenge, distress, drug therapy, emotion, ethics, fiction, love, marriage, psychiatry, schizophrenia, social, statistics | Tagged: , , , , , , , , | 11 Comments »

Rights and Love: a story

Posted by Dheeraj Kattula on September 7, 2010

He was a tall man. Dark and young, his name was James. He came for a full cup Chai* five years ago. He never stopped coming. To him, Chai was like petrol. It kept his engine running. He made friends easily. He became friends with Rafique on the very first day. Rafique was here to buy his bundle of beedis. The minute James realized that Rafique has just discontinued studies; he spent an hour with him to get him back to school. He failed. Of course! Who can convince a thug in the making. I have been hearing Rafique’s mother Salma begging him to study properly for the past 10 years now. It was of no avail. Rafique played the fool throughout his school life. He was no different from most of the guys in Dharavi. Honestly, at his age I was like that too. I left my home in Allepy when I was younger than Rafique. My original name is Abdullah. People now call me Nair. When I came to Mumbai, I wanted to be a hero, a star.  Fate had its way. I became a chaiwala*. I work hard and earn my roti*. That is a decent life. Isn’t it? At least I did not do crime.

Even though Rafique did not take advice, he realized that James was his well wisher. He became his friend and partner in his work. James was like a student who was interested in finding out our problems. He wanted to know about our lives. He wanted to find how we decided what was right and what was wrong. He wanted to know what we did when we perceived injustice. Rafique helped him meet up people in the slum. James came twice a week and did his job. He never missed his full cup special chai in my shop.

In about a year, James started educating us about our rights. He told us about how the real system ought to work. We knew how it worked. The constable on beat was the symbol of all authority to us. Give him a free cup of chai, he would not bother you for the day. The other symbol of power we know is the neta*. His ilk come here before the elections and would never show up again. The bigger guys here keep in touch with the netas. James taught us that these fellows are there to serve us and not get served by us. He also told us about the court system. In fact, that year Police picked Zuber and locked him up. They had suspected him in some bomb-blast case. We knew Zuber as a hard working tailor. He was cool and liberal. He could have no such links. James came to our rescue. It was then that we came to know that he was a lawyer. It seems he had studied in one of the best law colleges in India. I heard it is in Banglore. To us he was like God. Zuber was back. We learnt we could fight.

He fought few other court cases for our slum people. One was a divorce of Janaki and Kadam. Kadam’s drinking was routine. He beat his Janaki black and blue. One night she fell on a doorpost and bled from her scalp. It required 4 stitches to control that bleeding. Next weekday was the day James usually came to our slum. He spoke to Janaki and other neighbors and reported to the police. Police laughed at the issue. They said domestic fights between husband and wife are normal and they should be sorted at home and not police station. With James around they anyway had to register the case. James tried counseling Kadam. I would not have even tried. Some people won’t change. Atrocities on Janaki increased. Janaki decided to leave Kadam. Where would she go in Mumbai? How would she feed herself and her little five year old son Babul? She was concerned as Babul too was getting beaten regularly. She was also afraid that he could become like his father.

James fought for her and got her a divorce and also the custody of the child. Guys like Rafique too were not very happy with the divorce thing happening. Why? Aren’t other women adjusting with alcoholic men? Aren’t other women tolerating few beatings received from their husbands? James reasoned that we all have basic rights common to all mankind. One such thing is a right to life, liberty and security. He said our liberty should end one foot away from his neighbor. Here we had Kadam always violating his wife’s right to security and exercising his pseudo-liberty. He also felt Janaki could leave her husband exercising her right to liberty. I can very well understand that. Marriage should be based on mutual continual nurturing relationship. I was sort of convinced that she had a right to break the marriage. James also found Janaki a house maid’s job in Rajiv Gandhi Nagar, which is not too far from Dharavi. Kadam has died two years ago in a train traffic accident. Obviously, he should. He was totally drunk and was crossing the railway tracks. I wonder how he had survived 40 years on those tracks.

During last year’s elections most of our area’s people had gone to election campaign programs for money. There was very little business. I could have some personal time with James. I asked him about how he spent rest of the time. He said that he visited slums in Thane and Pune on a regular basis. He was doing the same thing that he has been doing to us, providing legal aid. I asked him how he managed to live. He smiled and said that few friends support him. Many of them were from a  network of Lawyers. There were others who also contributed. A dozen of them gave about Rs 1000/- each per month. That probably washed their conscience of the guilt of not doing anything for the poor. Many of those lawyers had monthly income running into Lakhs*. His wife Agnes was a teacher in a school and she earned another Rs 5000/-. They managed their livelihood in Mumbai with that money. It was difficult to imagine the kind of place that he was staying. He probably was not too better off than us.

Last year, he started coming less frequently. I was busy with pregnancy of my wife. I did not notice that I did not see him for six months. He came two weeks ago. He looked tired and worn out. His head was low as he walked past my shop.  I shouted for him, “ Saab. Chai?”  He pulled himself to the bench in my shop and sat down. I gave him his usual -special full cup Chai. He looked at me as he sipped and smiled. He looked older and mature. His dynamic force was gone. He was sober but looked to be in control. He finished his cup and went to meet others in the slum. I got busy with my work.

That evening I met Rafique. I told him that James had come that morning. I also shared my observations and expressed my wonder at the change. Rafique smiled and said, “You will never believe what he has gone through. He appears different, but this is what he really was- all the time that we saw him.” “Why? What happened? Tell me what you know”, I asked knowing very well that Rafique being close to James would know more.

Rafique narrated this story, “ Agnes, the wife of  James Sir had been suspecting him of having an affair with someone. She put strictures on where he could go, when he would be back, whom he would talk to and so on. She also felt that he was trying to kill her. Six months ago she stabbed James in his stomach with a knife. James was lucky; the knife pierced his bowels but spared his blood vessels. His neighbors heard the shriek and rescued him. They took him to Lokmanya Tilak Municipal General, Hopital in Sion. They did an operation and saved him. In the meantime his wife Agnes was arrested for attempted murder.”

“Oh! My God. It should be tough on James to go through all this”, I asked “What happened next?” Rafique said, “I am still shocked at what James has done. After his discharge, he fought for release of Agnes and won the case. He then got her treated in a psychiatric facility. They gave her shock treatment and medicines.” Rafique added, “She had not responded well to treatment. She is now on the best medicine in the world for her problem. James Sir takes her for blood tests every week. She still has not improved. She is suspicious of him even now. James Sir still lives with her, though he had to change the locality. The locals requested him to vacate. Our great lawyer chose not to fight.” I felt numbed. I could not say anything. Rafique had his cup of chai and left.

I could not sleep well that night. How can James live with his wife after what she did to him? How can he continue to be with her when she still poses a threat on his life? How can he share home with such a dangerous woman? Why can’t he divorce her and start a new life? He has helped so many people start afresh.

When he came today, I asked him, “Saab, Can I ask you something personal?” He agreed with his usual smile. “Saab, I heard what has been happening in your life from Rafique. I feel very bad about it. I want to know why you want to continue living with a person who is suspicious of you and has tried to even murder you? Can’t you choose a life of liberty that you want us to have? Why…?”

James then said, “Nair, we all have rights. Don’t you realize, if we all had our rights then nothing will be left. We all give up our rights for those we love. Don’t we? You have every right to eat from what you earn. Would you spend it eating Chicken Biryani alone or would you spend money to eat normal food with others in family? I have a right to liberty. I can divorce her as she would not allow me to be close with her, but I also have a duty to care for her. I have made a promise to be together in health and in disease, in happiness and in suffering. I will keep my promise even if it means to give up some of my freedom.

“But…You fight for our freedom”, I asked. He said, “Yes, I do fight for freedom and so many other rights. Many of our friends are unaware of their rights. If they are aware they would like to claim them. I help in raising awareness and helping fight to claim it. If someone does not want to claim a right for a different purpose, it is absolutely acceptable. It would be nice if that purpose is rational. Do you remember, last year Shinde joined BSc in Maths though he got a quota seat in Engineering. It is rare for someone to get to college level from Dharavi. Everyone scolded him. I knew he had a higher agenda. He wants to prove himself. A person who can run does not need crutches. Shinde will come up in life. He will live with self respect. Watch him. Anyway coming back to the point, rights give people a chance to make their life beautiful. Giving up your rights too can make life beautiful. In the case of me and Agnes, it is not yet beautiful. I agree I do not know what can happen to me, but that is alright. In a grand plan of people caring for their family, it is already beautiful.”

As I saw him walk away, I wondered James did give up much to be with us and has made life more beautiful for us. I found a new definition of love: That which makes the subject give up his/her rights to make life more beautiful for the object of his love.

————————————————-

*Chaiwala- One who deals with Tea.

*Roti- Pancake made from wheat. Contextual translation- bread.

*Neta– Leader, usually political.

*Lakh- 100,000.

*Saab– Sir

PS:( added on 25th September 2010) A sequel to this story “Love: Feeling, Reason and Choice” can be found here.

Posted in distress, drug therapy, education, emotion, ethics, fiction, gender, indian society, law, love, marriage, psychiatry, schizophrenia, stigma, women's issues | Tagged: , , , , , , , , , , , , , , , | 18 Comments »

eros@ergon.con*: a conversational story

Posted by Dheeraj Kattula on July 6, 2010

Recently an Indian CEO was sacked from his company because of a complaint of sexual harassment. He maintains what they had been in a consensual, flirtatious relationship that grew out of a close friendship with a colleague. This story triggered me to think on these issues.

Here is a fictitious story in form of conversations bringing out few issues which might have relevance to sexual harassment. I am no expert in this field. Though I have heard of many stories on domestic violence I have not heard much on sexual harassment. What I know is limited to conversations I have had with friends, patients and co-passengers in trains. I call the story “eros@ergon.con”.

*******

“Have you heard of what is happening?…This is bullshit going on here in our company.”

“I know. I work in Vicky’s team. I also know the reasons for all this.”

“What exactly happened?”

“See, Rashmi joined our team six months ago.”

“Is she the one we saw in the theatre last month?”

“Yes. She is the one. Remember, she was there with her boy-friend.”

“I remember being introduced to him. Ramesh is his name. He is in the accounts department…Ok. So, what did she do?”

“She has not been doing well in the job. Vikram had to admonish her for her mistakes. She felt offended. She filed a complaint of sexual harassment against Vicky.”

“Oh my goodness! I heard about that complaint but did not know the background. Anyone who knows Vicky can vouch for his integrity. It is terrible for his name to be stained like this. I wonder how he and his wife have taken this.”

“Rashmi has been roaming around with Ramesh whenever she is off duty. Their relationship is secret. Ramesh’s parents would never agree for their marriage. She is probably stressed. This gets carried to work. Instead of accepting responsibility she has used her trump card to defame Vicky.”

“Vicky’s name would clear off after the enquiries, but what about the trauma he is undergoing. She loses nothing for filing such a complaint.”

“She should be sacked for raising wrong allegation, when Vicky is cleared.”

“Some of these girls are crooked and some are just sensitive idiots. Last year, I had a complaint against me.”

“YOU!”

“Yes. It was a tough season. Our team leader Mrs Johnson wanted us to finish a job within 24 hours. She announced this at the end of the working day. It meant that I would not be going home that night. Our friend Raju was admitted in the hospital and I was to go to relieve his wife Laxmi for few hours. I was so pissed off at such untimely deadline, I pointed my middle finger as Mrs Johnson left the room. I basically meant **** off.”

“I can understand.”

“You have seen Swathi in the party two weeks ago. Didn’t you?”

“Oh! Is she the girl, who was sipping coffee when we were gulping beer in the party?”

“Yup! The very same girl. She saw my gesture. She went to Mrs Johnson and complained of this offensive gesture the next day.”

“Oh my God! What happened?”

“Mrs Johnson came and congratulated our team for staying up the whole night to finish the work. She also said that if we had not completed the job then she might have had to send us home to…as she said that she pointed her middle finger.”

“Really? She is cool.”

“We all had a good laugh.”

“Except Swathi…Perhaps.”

“We have to be sensitive to people around us. It is very true, but what if someone does not fit into our culture at all. What can we do if a person is overly sensitive? Thankfully Mrs Johnson is cool. If she was another sensitive nut, I would have had it.”

“It is a pity that Swathi could interpret a sign of frustration as a sexual gesture. But I respect her. She is good at her work and has good character. She is not like Urvashi, who sleeps with the boss to get promotions. In fact she has to do such shit to even retain her job.”

“Isn’t it interesting that everybody knows that the CEO is sleeping with a staff and nobody batters an eye lid. Urvashi’s father is a professor of Sanskrit and Indian Culture. I cannot believe how a girl like Urvashi is born into his family.”

“Who knows one fine day Urvashi might file a case in the court against the big boss for sexual harassment? Ha ha ha”

“Yes! The world would believe it to be harassment too. Poor girl…what other option does she have in this male dominated society…She had to do it…She kept it secret for long because she was stuck with fear…etc.”

“Absolutely true. These are bullshit arguments in her favour. She made her choice. She is doing this to move ahead in the corporate ladder and nothing else. If she really has some emotions for him, then she would realize with time that the CEO is just using her. Rashmi sleeping with Ramesh hurts the company in an indirect manner. It does not affect others directly. Urvashi’s sleeping with the boss is a lot different. She is growing in the ladder bypassing many worthy people. This would hurt the company more. Don’t you think so?”

“Incompetence and physical beauty put a girl at risk of being solicited for sex in her work place by people who can cover her incompetence. If she is ambitious, she uses her beauty to bait men around her to cover for her lacunae. I really do not think this kind of thing can be called sexual harassment. It is happening with the choice of the woman.”

“Whenever there is less difference between two people and the difference that a senior can make to them is huge, favours including sexual would tilt the scales. You can take the entertainment or fashion industry for example. At least this is not so much pronounced in our technological industry.

“True. In fact, the ones who can be considered as harassed because of sex like this are people like Mrs Johnson, Vikram and us. We work hard and finish our projects but we are sidelined to make way for people like Urvashi.”

“Hmmm…That is right. It is OK. In the long run we will catch up. So long as we enjoy our work and our compensation, why bother about others? Anyway, I got to go buddy. Bye for now. I will catch up with you in the mall this weekend.”

“Ok. Bye. Take care.”

************

(Inside a sub-urban train)

“Hey! What is up man? You look sad.”

“Sure. I do. I have reasons for it.”

“Want to share? You could…if you want to?”

“I got fired today.”

“Oh I see. Any reasons?”

“See, I am a laboratory technician in a college lab. I am in love with a final year student in the college. The college management feels that if they fire me they would send a strong signal to discourage romantic love inside the college.”

“Don’t mind this…Did you do something?”

“No…Nothing that you might imagine. We have not even touched each other. We know each other for the past three years. There was some Chemistry between us. We learnt more about each other over coffee. I proposed to her three months ago. She accepted. We have planned to get married after her graduation, which is two months from now…and now…I am unemployed.”

“What the hell is this? There is no complaint, no problem in your work or her studies, just arbitrary dismissal for being decently involved in love though there are marriage plans. This is surprising.”

“I am not surprised. Last month my friend gave a love letter to a colleague proposing to marry her. He got dismissed for this itself. She filed a complaint of sexual harassment.”

“Oh my God! This is ridiculous. I cannot stand this. Where do I go? Is there an escape from this kind of persecution? Looks like anyone can harass a man. A day will come when men file cases against men saying the boss is sexually harassing them. I have developed a phobia. I am going to leave working for a company. I will not start a company too, where I might have to employ people. I have to try my hand at politics. That is a safe place, where no one talks about even about the culpable ones. It is a place where the daring can brazen and the phobic can hide.”

“I don’t get you.”

“You don’t have to get me. Even I don’t get me. May be I need to consult my friends in NIMHANS $, Benguluru.”

*********

*

“Eros” in Greek means Romantic love

“Ergon” in Greek means Work

“Con” means

1. on the negative side

2. to trick; involve in abuse of confidence

$

NIMHANS- National Institute of Mental Health and Neurological Sciences ; a premier psychiatric facility in India

Posted in bussiness, distress, emotion, ethics, gender, indian society, law, love, management, social, stigma, women's issues | Tagged: , , , , , , , , , , , , , , | 5 Comments »

“He will get bed sores and die in about three months. Take care of him. Feed him with what he likes.”: Medical Model VS Family Practice Model

Posted by Dheeraj Kattula on June 29, 2010

He was discussing about his experiences after he came down from the mountains. He was doctor doing medical work in the communities based in nearby hills. He was posted there by our hospital for a couple of months. Of the many things he told that day, I remember this story clearly.

He had seen a 74 year old man with a fracture in his femur in a hilly village. He asked me what he would have done. It was a simple answer for me. I said, “You would have told them to bring him down to the hospital. We could give some charity, even if they cannot pay fully. The bones can be fixed.” There were five competent orthopaedic surgeons in our hospital at that time. He smiled sarcastically. He wanted to make a point, but what he said shocked me.

He had said, “I told them, that he might not live very long. He cannot move here and there because of his broken hip. He will get bed sores and die in about three months. Take care of him. Feed him with what he likes. Let him enjoy the time he has.”

I was filled with malaise. What?!!! How can a doctor say this kind of stuff? I couldn’t control myself. I asked him, “Wasn’t it inhuman? Fractures are treatable. Isn’t it? Then why not offer it. How can we give a death sentence for a treatable condition?”

He laughed at me as if I was talking rubbish. I heard his argument keenly. Probably, it was to rubbish his argument to boost my egoistic ethical pride. He said, “Listen, this old man has a son who is the only bread winner. His daughter-in-law is a house wife. His grandson is now in standard 10. His grand-daughter is in standard 8. It costs about Rs 5000/- to bring him down from the hills in a vehicle. The cost of treatment in the hospital would at least be Rs 30,000/-. They do not have that much of money. If I do send them down, they will have to bring him back after a discussion with a orthopaedic surgeon. In the bargain they would have spent off large amount of money. Just in case they go ahead and treat him, they will have to sell off their house. If they sell it off, then they will have to live in the street.”

I was listening. He went on, “If they spend all that they have, the grandson may not pursue education beyond high school. The grand-daughter would have to discontinue school to add to family income. All this might add one or two more years to a 74 year old man. Is adding a couple of years to such a man worth losing the future of a whole generation?”

It was a tough call. I was a new graduate then. I was trained in the medical model. I was supposed to tell the best medical treatment available to the patients and let them decide what they wanted. I realized this model absolves me of any feeling of guilt. The truth is I do have in my mind what is better, but still I would have done what is ‘right’. My friend’s argument did not convince me.

After about 6 years of that incident I am wondering if that ‘right’ that I would have done is really right?  What would I do if I were in that old man’s position? I am absolutely sure I would rather wish a better future for my grandchild than live a few extra years. I have heard grandparents in India bless their grand children, “Let my years be added to you.” Of course that does not mean that one can assume this sentiment in every case?

The point is that my friend is a family physician. His expertise is not only in managing health problems at a primary level but also in understanding clinical problems and treatment options in the light of socio-economic conditions and the values of the family. His model makes people happier and fulfilled more than the medical model which has the appearance of being more scientific. May be it is time the specialists learn to use the broader model. This can be done when; in addition to eliciting clinical histories clinicians spend some more time with patients in understanding their and their family context and expectations.

PS: This event happened about 6 years ago. Today, thanks to Chief Minister’s insurance scheme and 108 ambulance services, patients like the one described can get free treatment in our hospital.

Posted in challenge, children, Diagnosis, distress, economics, education, ethics, indian society, medicine, philosophy, social | Tagged: , , , , , , , , | 3 Comments »

“There is a limit to suffering one can take. I have to poison her before she brings disgrace.”

Posted by Dheeraj Kattula on April 5, 2010

She had an innocent smile of a child on her face. It was the first time I was seeing her. She was of dusky complexion, cute looks and shy behaviour. She had been on low dose anti-psychotics for few weeks. Her mother complained of her missed periods. Every day, we reassure a lot of people regarding menstrual abnormalities secondary to anti-psychotic use. As I reassured them, I could see that her mother was not satisfied. She complained of swelling in her lower abdomen. I smiled sarcastically at her ignorance. I felt she was worried thinking of menstrual blood getting accumulated down there.

Ignorance is fought with education. A couple of minutes of psycho-education could let them cool down, I thought. As I reassured them again, I noticed a smile of the patient. It was not the usual smile. It had a touch of mental retardation. I became serious. I knew she is a likely victim of sexual abuse. She was single, female, poor, beautiful and mentally disabled. I looked at her parents again. They obviously knew better than me of the possibilities. That was why they looked so distressed. They were afraid of the worst possibility- PREGNANCY.

The elderly couple also have a son. He has chronic Schizophrenia. He is dependent on them. The patient in front of me was dependent too. The grown up children cannot do any meaningful labour in the marketplace. Their mother is the bread winner. Their father is unable to work anymore because of old age. He minds the kids at home. The old lady was already in tears. I told her that she was not alone and such suffering is not uncommon. I realize these words are empty. Suffering hurts most when it hurts you.

She wiped her tears with the free end of her saree. She said “There is a limit to suffering one can take”, as she blew her nose she added, “I will have to poison her sometime, before she brings any disgrace to us.” I could understand her pain. I was shocked to see her daughter smile innocently as she heard this. I knew why this ghastly filicide had not happened till now. It is not tough to kill someone who would submit to you with a smile. It is impossible. Her mother loved her much. She just did not know how to handle her situation,  if at all there is a right way to handle it.

I wanted to send the patient for a pregnancy test. I also wanted to treat her with dignity as an individual with some ‘capacity’. So I asked her if ‘any man had come close’ to her. She agreed with a shy smile. My heart sank. Her mother nearly fainted. She reached out to the nearest bench that was available. I told them not to worry. We could find out if she is truly pregnant in the first place. Her missed periods could be due to medicine itself.

 Her parents did not want the test!!! Why?? I was shocked. They should be asking for it not me! They told me that a test would take time and if they do not go back in time, their schizophrenic son might wander away. Our OP assistant gave them an idea. Her father could return home and mother could take the patient back after the tests are over.

After a couple of hours, I saw them again. The pregnancy test was NEGATIVE. I sighed with relief. I am pro-life. I cannot think of recommending an abortion. We don’t do it in our hospital either. In fact if she was positive, I really do not know what I would/ should have done. Thank God! The old couple would not get another dependent into their family. They also did not have to kill a weak and helpless unborn child.

I told the mother to teach her to keep a distance from unknown men. Of course I know the ones who abuse are usually the known men. But here it was the case of an unknown man. Her mother told me that she had beaten her number of times to teach her that lesson. I wondered why she had to beat her daughter before an act was done! She knows her daughter and their situations better. I better not theorize how to handle these at this stage.  Anyway, now that the patient has experienced a ‘reward’ for the act, I predict she would continue to seek it. This is not my guess .It is the law of effect in maintaining behaviours called ‘operant conditioning’. I suspect that the mother understands this risk. She can never be in peace.

They left, temporarily relieved. I know God does not test us beyond what we can stand. I hope and pray they do not fail the test. We can imagine but we would never know tough it is. How could one help the patient live in safety? What should this mother do now, to prevent such happenings? What are her options given that are such daughters have right to liberty granted to them by International law like Convention on Rights of People with Disability? Where do local laws/ policies stand in situations like this?

Do comment and help me write the responses to the questions stated above in my future posts.

Posted in behavioral therapy, challenge, children, distress, ethics, law, love, mental retardation, schizophrenia, stigma, women's issues | Tagged: , , , , , , , , | 11 Comments »

“Why don’t you just leave your husband?”

Posted by Dheeraj Kattula on November 6, 2009

“Why don’t you just leave your husband?” Yes, this is what I said a couple of days to a patient of mine. How could I suggest such a thing? Leaving a marriage is not consistent with my worldview. Suggesting things is not consistent with psychological therapeutic practices. Then how on earth was I moved to do such a thing.

She had come into the hospital having eaten a crushed Oleander seed, a common method to kill oneself in this part of the world. She was 32 years old. She is married for 18 years, with an alcoholic man.  He beat the hell out of her everyday. He sold all the articles of the house to feed his habit of drinking. She had no ornaments of any kind, not even plastic stuff. He sold everything except the clothing upon her.Her husband never visited her, even when she was admitted into the Hospital. She worked hard as a daily wage laborer to feed her husband, son and herself. What she gets in return is slaps, punches and kicks.

She has tried her best to get justice. She thought the village elders would counsel him and stop the mindless violence at home. The elders of the village were men who enjoyed alcohol. Domestic violence is not an issue for them. In fact they supported him as he occasionally bought drinks for them. She had gone to her parents’ house to get some support. Her husband came to their house and dragged her out and took her back to his village. It was his right, after all she was ‘his’ wife. Her parents had complained to the local police station. The police told them that it was not their business to interfere in domestic problems of their house-hold. Her 16 year old son had already started drinking alcohol and was joining his father in violating her.

The woman I am talking about was not just another dumb illiterate woman. She was quite functional. She had saved a couple of women, who had attempted suicide by consuming Oleander seeds by taking them to the hospital. She knew Oleander seeds were deadly. She had high intention of her death. She survived by God’s grace.

Why is it that she was pushed to this extreme? She had tough life and had no hope. The system was against her. What else could she do? Escape! Where? From life…this is what she thought. I too think she should escape…not from life but from husband. I wish we had good police and legal aid for such women. The NGO’s are faaaar away from her.

She had never considered running away from the rogue husband of hers. She could easily work as a maid servant in a caring household and live comfortably. She did not know that it is possible. May be I was paternalistic in suggesting it. Whatever…it gave her hope. She decided to search for work somewhere. She is now living with her parents. Her husband is not bothered about her now as he feels she is weak and useless, especially as she had a recent hospital admission. She hopes to have a better life. At least she does not want to die now.

I wonder how contexts can change the way we view what is good. Socially, leaving a marriage is justifiable on basis of sexual infidelity. If a person has right to sexual purity of the partner, don’t they have for maintaining their own physical and mental integrity from the partner? If it is acceptable to leave a spouse if there is a trespass in sexual norms, why not it be acceptable to leave a spouse who violates physically and mentally?

I do not know the answers. You can help…just comment.I am busy thesedays, but could not help writing this.

Posted in distress, ethics, gender, indian society, marriage, social, suicide | Tagged: , , , , | 8 Comments »

” I could not tell him that he is HIV positive for two weeks ! “

Posted by Dheeraj Kattula on May 3, 2009

He was young and suave.  Like many educated metro-Indians, he spoke English more fluently than his mother tongue. I could see bandages around his wrists, which he tried to cover with a full sleeves shirt. His grandpa arranged his appointment a day before. He wanted to share things regarding the grandson in private. He did not want to reveal ‘personal’ things in front of the grandson to avoid embarrassment for everyone.redribbon

Basically his grandson had become a ‘drug addict’ and was using intravenous drugs. He was not seen in his college or the neighbourhood for a couple of days, when someone intimated the grandpa. His grandpa rushed to his college immediately on a taxi. The patient was found lying unconscious in his room. He was ALIVE! He was taken to a nearby hospital and was treated for sepsis with intravenous antibiotics. He had developed a major infection. All the points from which he had shot drugs were swollen and were oozing pus.

The patient’s only concern was to find out if he had to continue antibiotics or not. We could connect well. He was young , English speaking gentleman, who felt no one is interested in him and I was a person interested in all aspects of his life if not personally at least professionally :-).  I asked him to do a couple of blood tests. He readily agreed. I asked the lab technician to also do the HIV test. I had reasons to suspect a immuno-compromised state in him and also had the responsibility to protect our staff involved in his care.

I did not do the pre-test counseling or tell him about which tests were done. Reason- I did not want to rake up a emotionally disturbing issue in the beginning of a therapeutic relationship. I thought once I develop rapport and stabilized him, I would bring the topic, re-do the test and then declare the result to him.

Following this, I had a couple of sessions with him. His childhood experiences, his brought up under his mother after a painful divorce from the father, his troubled school life, his grief when his mother was diagnosed of cancer, bereavement  when she died, his lost love during college years, his one night stands and his encounters with the ‘drugs’. He was a talented man. He had a scrap-book full of songs he had written during intoxicated states. They resembled the songs written by rock stars. They lyrics were full of emotion, even if devoid of rhyme and reason 🙂

I had few sessions with his grand father too. He was an old man of about 75 years. His wife had died when he was relatively young. He brought up three children. The eldest was a nurse, mother of the patient. She had a troubled marriage with an alcoholic man. She found peace in divorce. She brought up her son all alone and sent him to a metro city for his graduate level education. She was diagnosed of cancer and subsequently died.  The old man had a paraplegic son who was dependent on him. The third child was a responsible one, who was single and worked in another part of the country. Grandpa had a comfortable pension, which was in addition to the pension the patient received. Their family income exceeded the salary of a consultant doctor of the hospital!

He came on a regular basis for two weeks. In the third week, I mustered courage to tell what had to be inevitably told.

I asked him,” What do you know about HIV?”

‘A bad disease.’

“How do you think it spreads?”

‘When a person is not careful during…’

“Ok” ,I added “also a child can get it from a HIV +ve mother during birth and people who share needles when they take drugs”. I could see anxiety in his eyes.

“Is there a possibility that you could get HIV?”

‘No, I cant get it.’

“I am saying if there is a slight possibility, as you have said already that…”

‘Yes, possible.’

“Would you like us to test you for it? The result would be between you and us. That is all”

‘Ok. Where can I do it?’

” Here itself. You can give a blood sample  now. We will tell you the result tomorrow. That should be Ok. Can you tell me what would you do, if you were positive?”

with a smile,  he said”Just live till I die.”

“I have some good news for you. Nowadays with newer medicines life expectancy in nearly equal to not having the disease if the person who is HIV +ve takes regular medicines. If you are +ve would you take these medicines?”

‘Sure, sir. Where will I get them?’

“Let us first do the test.Ok?”

Test was done. I already knew the report.

“What do you think is the result?”

long pause.

I nodded my head slowly. He understood. He did not mind me sharing this with grandpa.

” What should we do now?” they asked.

I told them all the details I had gathered from CMC, Vellore’s Department of Medicine ( and Infectious Disease ). They planned to go to the nearest centre for T4 cell counts within a week. I never saw them since then. Our staff told me that they had come, when I was on vacation. It seems he was looking much better nourished. Thank God, he is still alive…

I still wonder, why is it that I did not ‘break bad news’ for two weeks!!! It looks so simple now 🙂 Was it my own anxiety that he being unstable, might do something drastic like commit suicide or less lethal step of relapsing into drug use? Was it my psychological voyeurism to understand a ‘case’ with multiple problems from many dimensions?  Was it my fear to loose a psychotherapy client due to distress caused by a medical diagnosis? Was it me buying time to get the best information possible for his further management?

I do not know and might never know my own fears and motivations… I went by ‘gut’ and probably, was right. I feel timing was right in breaking bad news in this case. The reason is that the manner in which it happened and it’s outcome was smooth, predictable and under control.

Why did they then stop following up??? !!! I do not know, and I have no guesses. I hope that he is following up in the center which gives them Anti- Retro-viral Drugs and that they a managing his psychological and substance abuse related problems.

What do you think?

Posted in challenge, distress, drug therapy, emotion, ethics, psychotherapy, substance abuse, suicide | 2 Comments »

value, price and ethics

Posted by Dheeraj Kattula on April 26, 2009

A patient called us ‘dacoits’, a well meaning staff informed me. It is unthinkable for a team like ours, who chose to work for the poor to be perceived as a dacoits. That too by a patient! 

Why did that happen? The patient was ‘educated’ in the sense that he looked at maximum retail price (MRP) of drugs that we had issued and drug charges billed to him. There was a small discrepancy, which to him looked like daylight dacoity.

We buy drugs from good generic manufacturers like CMSI, LOCOST etc.We incur much higher costs of ordering, transport and stocking these generic medicines than brand ones. The brand suppliers call up to take orders, pay for the transport and at times give discounts also.

The generic ones do not offer these, so our costs are higher and margins lower. The MRP on their labels is less than break-even price for us. So I charge little higher than MRP. I believe it is right to do so. Even if I was a consumer I would have preferred this to buying branded medicines in pharmacies outside.

Why do we continue to use generics despite certain logistic difficulties?Let me illustrate with two drugs commonly used by psychiatrists.

 price-tableIt is far cheaper for the consumer to use generics. It is loss making for the hospitals, considering their other costs. So I use generic medicines for patients sake. When one sees the difference between the hospital’s price of generic medicine, which exceeds its MRP, one might conclude robbery in broad daylight. Asymmetry of information would never let him know that for few medicines, he has paid just about 5% of the market price!

One of my own staffs questioned me if charging more than MRP to cover costs is ethical! I think it is, if I want to deliver value to maximum number of patients by reducing their overall health-care expenditure. Look at the other option of stocking brand drugs, we will have profits but would alienate many poor due to high costs.

I can choose to do what looks good to others and what is easier for me. But then, I might end up harming many more people (especially the poor) than the few (in general middle class and the rich), who get dissatisfied with this way of charging. What do you think?

Posted in economics, ethics | 2 Comments »