Hinduism is a way of life, as well as a highly organized social and religious system. As the world’s third largest religion, Hinduism is practiced by people primarily from the Indian subcontinent. It is difficult to ascertain the origin of Hinduism, as it can neither be linked to any one individual nor associated with a definitive time. Widely regarded as the world’s oldest religion, Hinduism is a reflection of combined cultural, religious, and philosophical ideas that originated in India during the Vedic age (3000–1500 BCE).1
The word Hindu refers to the geographical origins of the river Indus in the north of India. In the Indian language, the river was called Sindhu, but was mistakenly identified as Hindu by foreigners. Thus the region became known as Hindustan (place of Hindus), its inhabitants were referred to as Hindus, and their religion was called Hinduism. To this day, the relationship between religion and the culture of the region is intertwined. Interestingly, the scriptures do not refer to the religion as Hinduism; rather, they refer to Sanatan Dharma (eternal duties or path). Other religions that are also considered as Sanatan Dharma include Jainism, Sikhism, and Buddhism. While each of these religions has unique characteristics, collectively they are seen as “branches of the same tree” and can trace their roots back to Hinduism.
This chapter begins with an overview of the core tenets of Hinduism. An extensive discussion of the religion is beyond the scope of this chapter; however, we have highlighted key concepts and principles that provide the foundation required to understand Hinduism’s impact on health care. The overview is followed by discussion of how Hindu perspectives view the concepts and constructs central to nursing, such as person, health, environment, nurse, and ethics. The notion of spirituality, as it is implicated in the religious tradition, will be highlighted throughout. We conclude with a discussion of how the religion and philosophy of Hinduism may influence the response to illness, for both patients and nurses.
It is important to state that the content of this chapter describes the most traditional views of the religion. Individuals of the Hindu faith differ tremendously in their understanding, interpretation, belief, and adherence to the concepts described. Our intention is to provide a deeper understanding of the religious concepts as a way of exploring the potential influence of religion on individuals. However, such information must be thoughtfully considered and applied and must not be used as a definitive guide from which to make assumptions about people’s beliefs, values, or thought processes.
The Hindu religion and way of life are traditionally characterized by five prominent themes. These include a belief in: one absolute being (Brahman); rebirth or reincarnation (Sansara or Samsara); law of cause and effect leading to a desire for right action (Karma); doctrine of religious and moral duties, conduct, and virtue (Dharma); and an ultimate goal of Moksha or liberation from the cycle of birth and rebirth. Although Hindus believe in one eternal, omniscient (all knowing), omnipresent (all pervading), omnipotent (unlimited) supreme being called Brahman or Ishwar, there are many manifestations of Brahman and the religion is characterized by a multiplicity of Gods and Goddesses among whom individuals are free to choose to worship. Each deity, in fact, represents an aspect of Brahman and these multiple manifestations should not be misunderstood as polytheism. Brahman is formless, infinite, eternal and beyond anything that we can conceive. Neither male nor female, Brahman can manifest itself in multiple forms, including Gods and Goddesses. The relationship between the many manifest deities and the unmanifest Brahman has been compared to the relationship between the sun and its rays. We cannot experience the sun itself, but we can experience its rays and the qualities as held by those rays. Although the sun’s rays are many, ultimately there is only one source: one sun.2
The most commonly worshipped deities are Vishnu, Shiva, Rama, Krishna, Ganesha, Kartikeya, Hanuman and the Goddesses Durga, Lakshmi, and Saraswati. Three principle deities, representing the three fundamental powers of nature—creation, preservation, and destruction—play an integral role in running the cosmos: Brahma (not to be confused with Brahman) is the God of creation, Vishnu is regarded as the preserver of the universe, and Shiva is the God of destruction. Rama and Krishna are human forms of God at different times in history who appear to destroy evil, protect saints, sages, and devotees, and be role models for humanity by their lives and teachings. Each God or Goddess is associated with specific qualities; for example, Saraswati is the Goddess of arts, music, knowledge, and wisdom, and Lakshmi is associated with wealth, fortune, courage, and fertility.
The pluralistic nature of Hinduism further reinforces the notion of Hinduism as a way of life. As a result, there is greater acceptance of multiple faiths and ways of worship, and the beliefs that guide how one lives life is more important than how, where, or to whom worship occurs.
Hindus believe that existence is eternal and that each life is a cycle in the ongoing journey or quest toward moksha. Moksha or mukti (freedom) does not refer to liberation from sin, as in Christianity. Instead, it refers to release from the human condition and karma (good or bad) and into a condition where time and space cease to exist and all is seen as one.3 The concepts of karma and dharma are central to how life unfolds. Karma is the universal law according to which every experience and action is the effect of a cause and is, in turn, a cause of an effect. The law of Karma essentially states that one’s actions determine what fruits one gets. Life events are based on the integrity with which the person has lived current as well as previous lives.4 Karma is everything that one has ever thought, spoken, done, or caused (intentionally or unintentionally) and is also that which one thinks, speaks, or does this very moment. Destiny, or bhagya, is different from karma, but is seen as a reflection of the fruit of karma. Thus, karma is not imposed by outside forces, either by God or by a punitive force, and it is not fate, as humans act with free will and therefore create their own destiny. Instead, it is accumulated through one’s thoughts, words and actions, and throughout the various cycles of birth and rebirth.
Dharma is the path of righteousness: living life according to the moral universal principles described in the scriptures. These principles guide humans to live with integrity and progress on the spiritual path toward unity with Brahman.5 A key principle involves refraining from attachment to the world as we see it. Worldly experiences are seen as temporary and illusionary (maya). The goal of detachment extends to materialistic things as well as relationships, given that all relationships and possessions are temporary; the objective, instead, is to turn toward Brahman. Living life without concern for the outcomes of the action is a way to foster detachment. The Bhagavad Gita (or Gita), a commonly quoted source of Vedic thought for Hindus, states in chapter 2, verse 47: “To action only you have right, not ever to its fruits. Let not fruits of actions be (your) motive (and let) not your attachment be to inaction.”6
Hindu teachings provide guidance in all aspects of life, including health and illness, and there is no one Hindu scripture. The content of the Gita quoted above reflects the teachings of Lord Krishna with respect to the science of realization and the process by which human beings can establish their eternal relationship with God. From a practical perspective, the Gita presents wisdom needed for one to achieve self-realization. The Vedas, or Books of Knowledge, are considered to be the oldest texts, dating back to at least 1500 BCE. The term Veda does not refer to any one particular book; rather, the collective Vedas encompass the vast literature of the early phase of Hindu thought. The Vedas are not considered to be human compositions; they are regarded as supreme knowledge that was directly revealed by Brahman. Vedic teachings are found in several different compositions and compilations and serve as guides for people in all they seek. Recitation of relevant Vedic hymns is important at significant times in one’s life, such as birth, marriage, death, or the start of a new venture.7
In the Hindu view, personhood is composed of two distinct but cojoined entities: spirit (atman) and matter (prakriti). Even though spirit and matter come together in a person, the individual continues to possess a duality that consists of a real self (the pure spirit) and a false self, the composite of matter and spirit.8 Internalized awareness of this is necessary to achieve enlightenment, at which point the soul is released from the cycle of birth and rebirth.
To understand the relationship between Hinduism and health, one first has to understand how the religion views the person and his or her relationship with God. Generally, most religions in the western world refer to the person as a holistic being with a body, mind, and spirit that are intertwined and inseparable.9 Alteration in any one element affects the other two and ultimately the whole person. Hinduism is similar in that the holistic view is important, but the relationship of various elements is understood differently, as described below. As well, there is a distinction between “spirit” and being spiritual; the term spirit may be translated as ghost or mental strength, but spiritualism is associated with the soul (adhyatma).
In Hinduism, the soul is the central entity. It is not the body that has a soul, but rather the soul has a body. The soul is the master of all activities, because the body can function only as long as there is soul within it.10 The body is the environment of the soul and is mortal, whereas the soul is immortal or eternal. When the soul leaves, the body ceases to function and death occurs; however, death is not forever, as the eternal soul is part of Brahman, the absolute being. In this way, the world recognizes and understands the body, but people cannot truly know the soul as it exists beyond possible perception.
The other name for Brahman, Paramatman, provides a clear understanding of the soul’s relevance to Hindus. The term is formed from parama, meaning “supreme” or “highest,” and atman, which means individual spirit, soul, or self. In this respect, Hindus have a very personal relationship with God, the “supreme soul.” After death, the objective is not to unite with family or any other person, as these physical relationships are temporary; instead, the objective is for the soul to completely reunite with the eternal Paramatman, without the need for further physical form. The soul is free of any illness or disease that the body may have had, but it carries with it the karma. This karma leads to the cycle of rebirth until eventually self-realization is attained, leading to moksha. With reference to the soul, the Gita states in chapter 2, verse 23: “Weapons cannot cut this (Self), fire cannot burn this, waters cannot wet and the wind cannot dry this.”11
Another distinction in Hinduism is that the soul is not limited to humans, but exists in every living being, including plants and animals, and all are a reflection of the absolute being. One way of addressing God is Sat-Chit-Anand. Sat is existence (or truth), thus everything that exists (animate and inanimate) is part of God. Chit is consciousness, and thus Sat-Chit refers to existence plus consciousness, and all living beings are that level of God. Anand refers to bliss and is found within the existence of human beings; thus, Sat-Chit-Anand is existence-consciousness-bliss that can be experienced by human beings through self-realization.
Hindus attach considerable importance to the relationship between the mind (mental activities) and the body (physical functions). Any disturbance in one affects the other and causes disease. Mental activities such as grief, fear, worry, anger, and sorrow are recognized as causative factors for physical illness, such as indigestion.12 Therefore, for maintaining one’s health, as well as for curing disease, it is required that both the mind and the body are kept in proper condition.
The mind plays a significant role in maintaining health by keeping itself and the senses under control. Buddhi is an important concept, and can be described as the combination of intelligence and understanding. It can also be thought of as the abstract notion of the brain; just as the brain is seen to have a central role in body functioning, all thoughts and actions come from buddhi. In this way, it is clear that there is a fundamental difference in how mind is understood in western thought and in Hinduism:
This difference lies in the fact that western psychology identifies consciousness with mind, and being with thought, and thought with soul, or the Self; whereas Indian psychology distinguishes mind from consciousness. This distinction is due to the fact that western psychology recognizes only one plane of experience, and gives no consideration to what Hindus call the pure cit, the supreme unconditional consciousness, the Being, which they regard as the real Self, or the soul, different from the rationalizing mind and realized in the super-conscious, or transcendental state. Pure unconditional consciousness cannot be the property of the mind, they believe, for it is the source of the mind’s apparent consciousness. Mind is said by the Hindu psychologist to be the “veiling power” of the pure consciousness, the Self, and it is associated with the Self only as a necessary condition of world experience.13
The distinction between mind and consciousness is important, since in western thought, mind is the route to achieving a peaceful and blissful state, and the unconscious or subconscious is a layer of the mind. For Hindus, however, the mind is important, but bliss and the un/subconscious are associated with soul and not the mind.
In Hindu religion, health is described as the equilibrium of mind, body, senses, and soul with nature.14 Given the intricate relationship between body, mind, and consciousness, it is not surprising that the concept of destiny is also salient to well-being. Destiny plays a key role in illness and disease. Destiny is what is meant to happen to one as a reflection of karma. Though it is, to some extent, outside one’s control and unchangeable, one’s response to present circumstance will influence what happens in the future, either in this or future lifetimes. Modern science identifies genetics as a salient factor in illness, but who or what determines one’s genes? Hindu philosophy attributes this to karma. Thus it may be destiny to have particular experiences in life, including illness, but how one copes with, learns from, and responds to the illness will influence the future.
Good health is said to be at the root of virtuous acts (dharma), acquirement of wealth (artha), gratification of desire (kama), and liberation from the world (moksha).15 Gunas is a term that denotes a set of qualities. The relative strength and combination of different gunas influences the nature of beings, including their actions, behaviors, and attachments to the objective world. In total, there are three gunas: The first guna is tamas, which is darkness, stupidity, and ignorance. The second guna is rajas, the stage when a person starts the active process of self-development, grows as a warrior, and then as a leader and organizer of other people. The third guna is sat-tva, which is purity, harmony, and bliss. The gunas are seen as the energies of the mind and are thus responsible for one’s psychological constitution. In equilibrium, the three gunas preserve the mind (and thus indirectly the body), maintaining it in a healthy state. Any disturbance in this equilibrium can lead to illness.16
A distinguishing feature of Hinduism is its fully fledged system of medicine. Ayurveda, or the science of healthy living, is a medical science that describes how to maintain one’s health and vigor, and also how to deal with illness.17 The term Ayur refers to life or lifespan, and Veda means knowledge. The knowledge of Ayurveda is said to be revealed by the creator, Brahma, and deals with subjects such as medicine, surgery, children’s diseases, hygiene, and prevention of illness. This knowledge was written into Samhitas or compendia. There are two major samhitas: Sushruta (representing the surgical aspect of medicine) and Charak or Caraka (symbolizing the medical aspect). Estimates regarding the dates of origin of these texts range from 4th century BCE to 5th century CE.18,19 These writings are said to be “so clear, intelligent, and scientific . . . that they might fit into any modern textbook.”20 In addition to information about health and illness, Carak Samhita also outlines the “team concept of medical care”21 by describing the fourfold nature of therapeutics as being comprised of physicians, patients, attendants (nurses), and drugs. This will be presented in greater detail later in the chapter.
Ayurveda’s scientific approach stems from Hindu philosophy, according to which the universe is composed of five basic elements: earth (prithvi), water (jala), fire (teja), air (vayu), and ether or space (akash). These five substances also constitute the human body and correspond respectively to firm tissue, humor, bile, breath, and organic cavities. While earth and space are inert, the three other substances are active and mutually interactive. Wind, fire, and water exist in the body in the forms of breath, bile, and mucus. The actions of these body elements are also influenced by seasons, climatic changes, and hygienic conditions, as well as the person’s particular constitution. Disequilibrium in any one of the elements invariably impacts on others and leads to various combinations of “troubles” or pathological conditions. This perspective is similar to Humorism, the ancient western theory regarding the makeup of the human body described by Greek and Roman physicians and philosophers. In this view, the human body is said to be filled with four humors—black bile, yellow bile, phlegm, and blood—that reflect the four elements—earth, fire, water, and air. Illness or disease was the result of excess or deficit in one of these humors.22
Ayurveda describes health as a multidimensional (physical, mental, social, and spiritual) positive state, not just as the absence of disease. There is an emphasis on prevention and health promotion; caring is privileged over curing; and quality of lifetime is more important than longevity. Each person is viewed as having a unique constitutional type and an unmatched set of life experiences; thus, health requires an individualized approach that consists of a total lifestyle and not just specific actions aimed at body, mind, or environment.23
In Ayurvedic thought, the body has two parts: physical (which includes biological/chemical processes) and the mind. The role of the mind is to activate, direct, and coordinate the sensory and motor organs, as well as to reason, deliberate, and discriminate. Body and mind make up the whole simultaneously, not sequentially, each being of equal value. Pathogenic factors of the body are attributed to vayu, pitta, and kapha, which are related to the elements of breath, bile, and mucus. Pathogenic factors of the mind are rajas and tamas, which are the first two gunas. All these pathogenic factors have their action in the body individually and in combination. Emotional states such as anger, fear, and anxiety can destabilize the physical domains, while pathogenic factors of the body can also produce mental disorders. In Ayurveda, there is no distinction between “physical” and “mental” illness; there is just illness. Consequently, pathogenic factors can be overcome in one of two ways. Therapies based on religious rights and physical propriety (medicines, proper diet, and proper daily routines) reconcile pathogenic factors of the body, and pathogenic factors of the mind require “spiritual and scriptural knowledge, patience, memory, and meditation.”24 However, given the integral relationship of the body and mind, one cannot effectively treat the body unless it is seen from the perspective of the spirit. Although it is acknowledged that addressing the psychic component may be elusive and time-consuming, dismissing it is considered bad medicine and unethical practice.25
The Carak also distinguishes between curable and incurable diseases and notes “no medicine is to be prescribed for incurable diseases.”26 This guidance with respect to “‘futile” treatment is for physicians, as it can be argued that there is no disease that cannot be cured with enlightened knowledge of sages who are well versed in the administration of elixirs and performance of spiritual acts.27 Thus, even when treatment is futile, hope is maintained, and while death can be anticipated, it cannot be predicted with respect to specified time.
A comprehensive understanding of health in Ayurveda also includes a social dimension.28 Control of sense organs and positive social relationships are part of good conduct, which is important for health and well-being. The fundamental belief is that humans are social animals who require positive social relationships to achieve physical and mental well-being. A person is expected to be happy and healthy on a personal level, but as the person is also a social being, the emphasis on personal health is extended to social health and involves concerns for the well-being of others in the community. Wrongful actions are seen as adding to stress and disharmony of the individual and the collective. Attributes of good conduct in Hindu philosophy range from good grooming and hygiene to engaging in good work that occupies the mind and reverence for the divine.29
In summary, medicine and morals are closely related in Hinduism. Health is complex, comprehensive, and a result of one’s conduct in all spheres of life. Hindu philosophy encompasses an elaborate system of medicine, Ayurveda, which discusses health promotion, illness prevention, and also outlines elaborate curative treatments for specific conditions. As a science, Ayurveda’s purpose is to ensure the health of body and mind; as a philosophy, its goals go beyond the preservation of health and curing of disease. Illness is viewed in holistic terms, with no distinction between physical and mental illness. Thus all treatment must also be holistic and inclusive of medicine, diet, daily rituals, spiritual and scriptural knowledge, prayer, and meditation. Health is both personal and social, and requires actions aimed at preserving personal as well as social morality.
Hindu philosophy gives significance to persons being active agents in their own lives. Health is defined as the state of equilibrium, and prevention of disease is achieved through diet, conduct, and regimens. Hygienic practices and other health measures are enforced through the regimens and religious observance.30 However, although the person is expected to play a major role in maintaining health and well-being through thoughts and actions, a patient’s role in recovery from illness or disease is less prominent. Of the four therapeutic factors (physician, medicament, attendant, and patient) described by the Carak as responsible for curing disease, patient actions are said to have the least important role. However, for optimal effectiveness, each factor needs to “have the requisite qualities.”31 The qualities of the patient are described as: “good memory, obedience, fearlessness, and uninhibited expression.”32 The use of the term “fearless” here is in reference to controlling mental stress, such as fear and anxiety, which would further aggravate the disease. In illness, the efforts of the patient are directed toward following instructions of the physician and in giving a correct history of the disease. Thus the role of a person in illness complements that of the physician, treatment, and attendant by adherence to therapeutic and dharmic regimens.
In Hindu philosophy, the environment is not separate from the person; all living things are part of the absolute being. The environment is also not limited to the physical environment that can be seen or felt, it extends to the unseen consciousness. Diet, climate, soil, season, time, and place are factors that need to be considered in relation to health, and the position of the individual in the universe is also important. Even in ancient times, Hindus had a highly developed knowledge of planets and the universe, and the relationship between the universe, its planets, and God is described in the Vedas. Thus, Hindus believe that a person’s health may be influenced by many environmental factors, including astrological ones. Hindu astrology extends beyond the zodiac system found in western astrology and includes the Nakshatra system.33
A key concept associated with environment is that of purity. Hindus believe that it is important to keep mind, body, and environment pure and free of wrongdoing or toxins. Purity in thought is related to good intention. Purity in mind is important for trust. Purity of body is maintained through strict hygienic practices. For example, awakening before sunrise and cleaning feet and excretory organs frequently are practices that promote intelligence, purity, longevity, and auspiciousness.34 Saliva and body discharges are considered to be impure and polluting (tamsic); in addition, menstruation is seen as very polluting and contributes to a negative attitude toward women. Purity also exists in different degrees, in that some objects are more pure (suddha) than others. For example, gold is considered to be more pure than copper. As well, some items (such as water from the Ganges river) are not only pure in themselves, but also have the ability to purify other objects that come in contact with them.35
A concept related to purity is that of auspiciousness (subh) and inauspiciousness (asubha). Subha is related to the time and manner in which events take place. There are days or times, based on the lunar calendar, that are considered to be either auspicious or inauspicious for critical events such as marriages or prayer rituals. Performing rituals (and treatments) at subh times is integral to the positive effects associated with the ritual. Purity/impurity and subha/asubha are part of one’s daily life, thus the rituals of purification play an important role in maintaining dharma and well-being. For example, although childbirth is an auspicious (subh) event, it has many associated impurities, such as body fluid discharge, which renders both mother and baby impure. There are, however, several rituals and social ceremonies that are conducted to manage the impurities effectively. Overall, purity/impurity and subh/asubh can be described as two vital components of a Hindu person’s life that are sufficiently complex and often require counsel of carefully trained persons such as priests.36
Ancient medical literature highlights four aspects of therapeutics: physician, medicament, attendant, and patient. Among these factors, physicians occupy the most prominent place by virtue of their knowledge, administrative position, and prescribing capacity. The desired qualities of physicians include: excellence in medical knowledge, extensive practical experience, dexterity, and purity.37 Excellence in knowledge is achieved through learning from preceptors and studying scriptures. The virtue of purity is important, as it is associated with a spiritual force that the physician brings to healing. Although the actions of the physician are said to be all important, doctors do not have the right to be deterministic with respect to health outcomes or decision making; medical science cannot overshadow karma or the influence of forces of higher consciousness.
Medicament is something that exerts a therapeutic action when administered. The qualities of medicament to consider include abundance, suitability, multiple form, and potency. Medications should be potent, free from infection, and amenable to different forms to suit the nature of the patient and the illness. The physician is expected to acquire this knowledge and prescribe accordingly, after taking into consideration the physical and spiritual nature of the patient.
There is no specific reference to “nurse” within the Hindu texts; however, the history of India is said to “reveal a more complete description of nursing principles and practices than that of any other ancient civilization.”38 The description of “attendant” in the Carak can be considered to be equivalent to nurse. The desired qualities of a medical attendant include knowledge of nursing, affection, and purity. Attendants were also expected to be “endowed with good conduct, cleanliness, character, devotion, dexterity, and sympathy and . . . (be) conversant with the art of nursing and good in administering therapies.”39 Other attributes of attendants include being:
. . . endued with kindness, skilled in every kind of service that a patient may require, endued with general cleverness, competent to cook food and curries, clever in bathing or washing a patient, well conversant in rubbing or pressing the limbs, or raising the patient or assisting him in walking or moving about, well skilled in making or cleaning beds, competent to pound drugs, or ready, patient, and skilful in waiting upon one that is ailing, and never unwilling to do any act that they may be commanded (by the physician or patient) to do.40
Attendants were expected to be willing workers who did not speak ill of anybody and indefatigably followed instructions of the physician. In addition to attendants, hospitals also needed people who were well versed with music and the recitation of verses and stories.41
In ancient times, the attendants were generally male, or in rare cases, old women who belonged to subcastes of the Brahmin and priestly orders.42,43 Modern nursing was introduced in India in the 17th century by the Portuguese when they conquered Goa. For many years, nursing training was only given to European and Anglo-Indians. The first Indian female to have received nursing training was Bai Kashibhai Ganpat in 1891. In succeeding years, nursing schools were established all over the country; however, this was in the era of colonization and thus strongly influenced by Christian values. The Second World War led to an acute shortage of nurses in the country, and subsequently short intensive training programs were established for auxiliary nursing service where young women of “every caste and creed” were trained.44
It is important to acknowledge that nursing as a profession is not viewed very positively by contemporary Indian culture, particularly as it became a female-dominant profession. Nursing is viewed as having boundaries for physical, intimate tasks, and gender relationships that are different from those culturally acceptable for women, especially young women, in traditional Indian society. The lack of appreciation for contemporary nursing may also be associated with the notion that women, especially premenopausal women, are inherently regarded as less pure, which, in turn, may compromise the environment and the power of the spiritual force available for healing. The description of attendant as someone who carries out tasks that are “commanded by the physician or patient” suggests that nursing was largely viewed in a dependent role, with the nurse being regarded as a “handmaiden.” This perpetuates the notion of a strong hierarchy, and privileges the physician role with significantly more respect and prestige.
Yet while the profession of nursing is only slowly gaining acceptance and stature within the modern community, the need for nursing services is clearly acknowledged and desired in the roots of Hinduism. Indeed, knowledge is clearly described as an essential quality of the attendant. Nurses were expected to possess knowledge and skill as well as virtue, and we can thus conclude that even in ancient times, the dependent role of nurses was augmented by the view of nurses as skilled knowledge workers. In addition, the Carak describes the four aspects of therapeutics in an integrated manner, with the reestablishment of equilibrium (health) depending on the strength of the total quadruple. Each of the four factors, including nursing, was therefore seen as a critical element in an integrated approach to health.
Although the need for nursing activities and nurses was recognized in the Carak, for most Hindus such functions are closely related to the concept of seva. Seva is translated as selfless service or work offered to God. In Indian culture, when one thinks of seva, particularly in the context of caring for the ill, one immediately thinks of family. The duty to do seva rests primarily with the son(s) and daughter(s)-in-law as it is their dharma. Such seva is akin to generating punya (good karma). Care giving thus becomes an obligation of the family, particularly for the males. From the traditional families’ perspective, the nurse’s role is to support the family and, as needed, direct them in particular aspects of care.45 In today’s society, however, the ability of family to do seva is becoming increasingly limited and reliance on outsiders is becoming increasingly needed and valued. This need further supports the recognition of nursing as a valued profession in contemporary society.
In Hinduism, there is no one source for moral authority. Hindu religious literature can be divided into two categories: Shruti: that which has been heard (revealed truth); and Smriti: that which has been remembered (remembered truth). The Vedas are considered to be the original scriptures of Hindu teachings (Smriti) and contain spiritual knowledge that encompasses all aspects of life. The highest authority is that of enlightened persons or incarnations of God (e.g., Rama and Krishna), as they are said to possess all knowledge, past, present, and future.
For the followers of the religion, the two most commonly used books to provide the day-to-day guidance are the Ramayana and Gita. Both books belong to the Smriti category as they are descriptions of historical epics. The Ramayana provides a description of Lord Rama’s life, and in addition to showing the glory of God, it “provides a code of conduct, the role models for the family, and the philosophy for life here on earth and in the hereafter.”46 The Bhagavad Gita teaches the causation and the effects of karma and how to deal with its manifestations. It also teaches that human beings have free will and ability to make intelligent choices, which in turn may alter the manifestation of the karma.47 The Gita is frequently regarded as the highest and most practical written expression of Hindu philosophy. For practical purposes, the conduct of Lord Rama and the teachings of Lord Krishna, both of whom took human form in times of need, serve as guides for conduct, decision making, and adherence to dharmic concepts for the average Hindu person.
In Hinduism, there is synergy between philosophical wisdom and ethical excellence, as the scriptures assert that moral and ethical excellence is a prerequisite to the pursuit of knowledge. Hindu ethics does not focus only on what is conducive or necessary for survival of a particular individual or species. Instead, it prescribes the disciplines for a spiritual life that should be observed both consciously and unconsciously.48
Hindu ethics is a systematic progression from the objective to subjective, and ultimately to super-ethical level.49 Objective level ethics is described as social ethics and is guided by dharma. Each individual is said to pass through four stages of life: student, householder (family, procreation, obligations to kith and kin), forest-dweller (life of solitude and meditation, where demands of mind and senses yield to demands of the soul), and hermit (detachment to pursue the goal of self-realization). This scheme answers the moral question of how one should live. Thus morality, to some extent, is influenced by the stage of life and is relative.
In the first stage of objective ethics, “morality is represented by social codes demanding external conformity” and conscience is driven by fear of punishment for duties not done.50 The subsequent stage of subjective ethics focuses on virtues as opposed to duties. Virtue is directed from within and arises from feelings of preference and self-respect; the “must do” orientation is transformed to “ought.” Virtue has three parts: Manasa (mind), Vacha (speech), and Karma (action). Virtues of the mind are seen as kindness, detachment, piety; virtues of speech are evident through truthfulness, benevolence, and recitation of scriptures; and virtues of action include seva, social service, and good will toward others.51 The third stage of ethics moves from social and personal, to transcendental. The transcendental has been characterized as the “post-ethical plane of being.” At this level, ethics loses its substance as all empirical contradictions are transcended. It is important to note that this transcendence is not provided by an external source (as salvation is, e.g.); rather, the real self is already perfect but had been concealed by maya (illusion).
This duality of self is also evident in how truth is understood. Truth is of two kinds: scientific or empirical knowledge and transcendental or yogic knowledge. The former truth is perceived by the five ordinary senses or inferred from data they provide, and the latter is perceived by the subtle spiritual power of yoga.52 Empirical knowledge is substantiated through inference and reasoning; transcendental knowledge comes with enlightenment.
Within Hinduism there is a call for promoting social welfare by helping society rid itself of selfishness, cruelty, greed, and other vices, thereby “creat[ing] an environment helpful to the pursuit of the highest good, which transcends society.”53 A person endowed with social consciousness is said to have a threefold debt to discharge. The first is a debt to God for all the natural amenities (sun, rain, wind, etc.), which is paid through worship and prayer. The second is the debt to teachers or saints from whom we inherit the spiritual culture, which is paid through the regular study of scriptures. Lastly, there is a debt to parents and ancestors from whom we receive our physical bodies, which is paid through procreation and ensuring the preservation of the lineage.54 The notion of debt and duty to family takes on considerable importance in the day-to-day lives of Hindus. Despite having an ultimate spiritual goal of detachment, traditional Hindus have strong attachments and bonds to immediate and extended family in their current life. Strong families and family values are foundational to a strong society, which in turn is essential for good health.
Hinduism is largely a way of life with variations in rituals, traditions, and the particular deity of worship; thus, the influence of the religion on a patient or nurse can differ tremendously. It can also be independent of the degree of expressed religiosity of the individual. However, as the religion and way of life are so intertwined, even Hindus who may not be adherent to religious practices are likely to be inherently influenced to some extent by these core tenets. These individuals may thus display signs of influence without any concrete knowledge of the specific concepts mentioned in this chapter. The foundational concepts of karma and dharma will likely influence both patients and nurses in their responses and actions. In addition, Crawford identifies five principles as being of critical significance for most Hindus: purity, self-control, detachment, truth, and nonviolence (ahimsa).55 These may further influence the day-to-day experiences and actions with respect to how one strives to meet their dharmic duties, particularly at times when health is compromised. For an individual in need of health care services, two key areas that are likely to show the influence of Hinduism are response to illness and decision making.
A Hindu patient may view illness as karma and rely on the principles of dharma to respond to it. With this line of thinking, everything that happens is a result of karma. Illness is not random and questions such as “why me?” can be answered by “it is karma.” Suffering can be seen as a way of releasing the debt for past negative karma as well as an opportunity to be tested and to learn from the difficult experience. Acceptance of pain can be viewed as progress toward the spiritual goal. The Hindu patient will acknowledge and may find comfort in the belief that while the body may be in pain, the soul is not harmed. In the Gita, Lord Krishna advises Arjuna to learn to endure fleeting things like pleasure and pain. The lesson is that when suffering and joy are equal, one has courage and is “fit for immortality.”56
A potential challenge for patients with Hindu faith is experienced when karma is viewed as fatalism and passivity, or when the patients’ belief in karma is interpreted by others as fatalism. The risk is that these patients will not get the support, education, and ongoing efforts to reduce the pain and suffering because they are seen as unmotivated. It is important that acceptance is not misunderstood as a desire for inaction. In fact, Hindu tradition guides one to avoid inaction and recognizes that while the consequences of past deeds must be accepted, actions taken today are important influences for the future. Patients can thus be encouraged to actively manage their condition, while accepting the outcome without the attribution of success or failure.57,58 One’s duty is always to do one’s best and accept the outcomes, regardless of what they may be.
Challenges may also be encountered in discussions where quality of life is the salient principle for decision making regarding treatment. Given the belief that what is happening is Karma and that one’s dharma is to accept it and live as best as one can, it may be difficult for a Hindu patient or nurse to see a poor quality of life as a valid argument for discontinuing treatment, such as long-term dialysis. Rather, such decisions are more likely to be influenced by the patient’s age and stage of life.
The illness experience is also influenced by the understanding of the interrelationship between the body, mind, spirit, and even social conduct. The concept of holism is not just important in understanding the etiology of illness, but also in the response made to it. Desired interventions may be focused not only on biomedical therapies, but also on religious and spiritual rituals. Current health care discourse on religion and spirituality often differentiates between the two, with religion being described as a defined set of practices around a traditionally defined belief, and spirituality as a broad construct of lived experience with a focus on the I, the self, and one’s relationship with the universe.59 For Hindus, either as patients or nurses, the spiritual goal of consciousness is the essence of the religion. The quest for consciousness is associated with detachment and acceptance, where ultimately I ceases to exist as an individual and unites with Brahman.
The notion of spiritual distress may also be problematic for Hindu patients and/or nurses. The spirit or the soul does not have distress; these feelings are a result of pathogenic factors of the mind and the influence of the gunas. Thus, illness and distress are difficult to subdivide into mental, physical, and spiritual. The mind has a significant role in illness, not just because of its potential influence on the body, but also because buddhi is critical to the appropriate response. Thus, psychosocial and spiritual aspects of care are significant parts of the overall care experience and Hindus are also more likely to accept and desire a plurality of approaches to care. As noted in the Carak, pathogenic factors can be overcome by physical proprieties including medicine and diet, and religious rites, as well as meditation, prayer, and scriptural knowledge. Thus, the desire for a spiritual healer is likely to be seen as a natural part of care and not an “alternative” to medical care. Patients may also look to their doctors and nurses to integrate these spiritual aspects into prescribed treatments. Where physical and spiritual care is offered by different individuals or “specialists,” integration of the two perspectives will be critical.
Hinduism also encourages self-healing, characterized by: testing the powers of one’s mind constructively and positively; listening to the intelligence and wisdom of one’s body; harnessing the creativity and positive energy of one’s emotions; and finding one’s place in the greater scheme of things.60 Even though the Carak notes that the physician has the most prominent role in therapeutics, it is also clearly stated that the patient’s actions must complement that of the physician. The patient is expected to have an active role in healing, and this role needs to be acknowledged and supported.
Hindu ethics is said to have a contextual structure, where the right or the dharmic thing to do is guided by the demands of the situation. Hindu ethics is not absolute and does not rely on authoritarianism or objective norms for conduct, nor is it relativist by privileging the individual and his or her preference and happiness. Instead, Hinduism gives importance to rational authority; reason is important but is augmented by revelation. Unlike western thought, where revelation is often though not exclusively seen as external, for a Hindu, revelation is an internal activity, similar to intuition and reflective of the holistic nature of the person. In the end, the individual is guided by both reason and teachings from the scriptures to determine what is of ultimate value in the particular situation.61 Decisions may also be influenced by the extent to which a patient will still be able to carry out desired practices and rituals that are seen as being a critical part of one’s dharmic life.
Hindu society and philosophy are characterized by the notion of collectivism, where decisions are based not on the individual good, but rather the good of the collective. Although this may seem like a paradox, as the ultimate objective is to achieve moksha as an individual, we must remember that the individual body is recognized as a “false self.” The real self is one that is part of a larger consciousness. Thus, the decisions are guided not by what is right for the “false self” but by what will lead to revelation of the true self. Decisions are therefore based on what is “good” for others, family and society, and based on actions that fulfill one’s duty toward others, including ancestors, teachers, and God. It is not surprising then that the stage of life may significantly influence the response to illness and treatment, such as pursuing more aggressive action when there are obligations to family, and a different response when the objective is a focus on detachment and self-realization.62
Notions of purity and auspiciousness can also influence decisions. For example: for a woman, dying before her husband is considered to be a more auspicious death and is preferred over becoming a widow. In addition, there are other attributes associated with what is considered “a good death.” A good death is one that happens at home, and over which a person has control. Death is a social event and the collective expression of love and grief from the extended family allows the patient to participate in this ritual. Prolonging life artificially is seen to be of little value. However, it is important not to interpret this as leading to all refusals of resuscitation or mechanical support. Unless there is clear evidence of “fatal signs,” extraordinary means are not prohibited on either moral or medical grounds.63 Again, one has to view the situation holistically to determine the appropriate course of action.
An area of potential contention between western health care practices and Hindu beliefs is the area of “full disclosure” regarding a diagnosis and prognosis. Though western practitioners might feel obliged to offer complete information about prognosis including imminent death, Hindu beliefs would say that it is inappropriate to predict the timing of death. The impending death is not explicitly pronounced because words have power; “naming death may invite it too quickly.”64 All physicians can truly say is that there is nothing more they can offer with respect to treatment (as they know it). Western practitioners may see this as “withholding the truth” or offering false hope, but for Hindu patients, acceptance and hope can coexist. Even when the physician has nothing more to offer, interventions such as prayer and other religious rituals can still offer some hope. Death must neither be hastened nor resisted as an enemy of life;65 instead, it is the last step in the journey of this birth and a step toward the ultimate destination of moksha. For these reasons, it is crucial that health care workers clearly ascertain the wishes of the patient before making any statements that can be interpreted as predictions.
Although Indian society does not see nursing as a high status profession, in our experience, Hindu nurses tend to view their role in very positive terms. Duty toward self and others is a salient feature of Hindu spirituality. In Christian faith, this may be a reflection of love. This love is unconditional despite the unattractiveness of the object/sinner; caring is to show God’s love.66 For Hindus, caring is serving God, who resides in each being. Seva is dharma. Nursing can be seen as an opportunity to provide the ultimate selfless seva, as there is little materialistic gain such as money or prestige.67 The ability to provide such seva can be seen as a privilege, as it provides an opportunity for punya or doing righteous actions.
The ancient Hindu text Caraka describes the role of the nurse as subservient to the physician, but the fourfold nature of therapeutics clearly establishes this to be an interdependent and not a dependent role. The ancient view of nurses as attendants has evolved into nurses with professional knowledge and accountability that includes, but also extends beyond, doing what is commanded by the patient or the physicians. Nursing roles today comprise elements of both the attendant and the healer, and thus the desired attributes and expectations for Hindu nurses will likely be derived from the description of both attendant and physician.
A therapeutic relationship is at the heart of nursing, and for Hindu nurses, the relationship is not just with the individual but extends to a range of family members. Recognizing the value that may be placed on the family’s role in care giving, the nurse is likely to encourage, and perhaps even impose, such a role for particular family members. Therefore, if the practice environment privileges individualism to the extent that family is excluded or defined very narrowly, Hindu nurses practicing in western society can be at risk of experiencing moral conflict. In addition, for Hindu nurses, the nurse–client relationship is likely to be characterized by a participative approach. Persons are regarded as both dependent and responsible and they are viewed as being “in equal need of beneficence and autonomy.”68 Concepts such as client empowerment, patient choice, and patient-centered care are consistent with Hindu thought and are likely to resonate with the Hindu nurse. The attendant functions also reflect actions that are characterized in the current nursing ethos as “being with” or “being present” to witness and share the illness experience, without a need for specific intervention. The interdependent nature of nursing and the team approach to care are concepts that are consistent with Hindu philosophy as outlined in the Carak. Authenticity and trustworthiness are crucial characteristics that patients may look for and nurses themselves will value greatly. For the Hindu nurse, compassion and kindness can be viewed as dharma. As well, the nurse may be more process-oriented than outcomes-oriented, as the outcomes are influenced not only by actions of the individuals involved, but also by karma.
The extent to which Hindu nurses are influenced by the traditional teachings is likely to influence how nurses view their role toward the patient, family, and even larger society. For example, acceptance is a foundational value in Hindu philosophy. Hindu nurses may therefore see it as their duty to help patients strive toward acceptance. This emphasis toward acceptance may, at times, be in contrast to patients who see disease and illness as something to be conquered. However, the contextual and situational nature of moral reasoning means that nurses may provide external guidance, but recognize that external opinions must be integrated into one’s own, and ultimate decision making rests with the individual patient. For the Hindu nurse, body, mind, and spirit are intertwined in a way that they cannot be separated. The mind influences the body, but the physical conditions of one’s environment also influence the mind. Spirituality is understood as much more than religion, yet the rituals associated with religion are also considered powerful.
Another area of potential influence is the Hindu nurses’ understanding of knowledge development. There is general consensus in the nursing literature that there are several ways of knowing that can be classified as scientific and nonscientific, and both ways are equally important. This view is supported by western psychology in as far as there is recognition of the nonscientific approach to knowledge; however, the psychology literature privileges scientific knowledge and regards the nonscientific ways of knowing as celebrating the possibility of error.69 For the Hindu nurse, both scientific and nonscientific ways of knowing are equally valid, but the nonscientific knowledge and reasoning extend beyond what has been characterized as professional craft knowledge to knowledge derived from one’s consciousness and the soul.70 Thus, the nurse is likely to hold intuitive and personal knowledge in high regard as it comes not just from the mind but from the soul.
On a broader social level, nurses influenced by Hindu thought are more likely to have a holistic understanding of health that includes a social dimension with a focus on prevention of illness and disease, promotion of health, and concern with the general well-being of persons in the community (social determinants of health). This understanding of rules of good conduct will likely extend to “an ethic of public health.”71 Promoting social welfare is an important element of Hindu ethics, thus creating a propensity for the Hindu nurse to be involved in public health and public policy initiatives.
In summary, even in illness, the central concepts of karma and dharma and holistic understanding of the person are paramount. These concepts can be expected to shape both the understanding of, as well as the response to, illness, including treatment decisions and who is involved in care. The illness experience is likely to be characterized by the co-existence of acceptance, hope, and a belief in possibilities beyond those offered by the mortal treatment team. Despite the odds or immediate outcomes, active commitment to one’s duty is essential as the fruits of action extend beyond this life. This is applicable to both patients and nurses. Like all aspects of Hindu existence, illness experience is also characterized by holism where mental, physical, and spiritual health and illness cannot be separately distinguished. As a result, the desired treatment is likely to include support for the physical, mental, spiritual, and religious dimensions of one’s being.
In conclusion, Hinduism has much to offer with respect to a holistic understanding of health, illness, and the human person. The relationship between religion, health, and health care is indistinguishable. Hinduism is more than a religion; it is a way of life, complete with its own indigenous system of medicine and a definition of health that extends beyond the body, mind, and spirit. For Hindus, it is not the body that has a soul, but rather the soul that has a body. While the body is mortal and subject to illness, the soul is eternal consciousness. The soul acquires karma through one’s actions, thoughts, and deeds, and karma is responsible for the events of one’s life, including illness. Thus, it is clear that while Hindus accept what happens to them as karma, they also recognize that karma is not externally driven. Individual persons, through their own actions, take control of their destiny. Hindus are, therefore, advised to live their life according to dharma or righteous actions, which in turn will lead to self-realization and freedom from the cycle of birth and rebirth.
Hindu philosophy views health as something that is much more than the absence of disease. It is multidimensional and consists of physical, mental, social, and spiritual components that are interrelated to achieve a state of equilibrium with nature. Such a positive view of health requires an approach that is different from the disease-oriented view, where complaints are connected to pathology. For Hindus, how one lives life with respect to integrity and conduct are critical components of maintaining health and recovering from illness. Illness is also holistic in that there is no distinction between physical illness and mental illness. Recovery from all illness requires attention to the physical, mental, emotional, and spiritual domains in an integrated fashion.
Hinduism teaches one to be extremely patient-centered and focus on the illness experience. Every person is a unique being, not just in their constitution, but also in their life experience. Thus it is important to understand and address the total illness experience. Good medicine and care requires that the spiritual dimension of a person be addressed along with the physical, mental, and emotional aspects. It is clear that medicine has a moral structure and health care practitioners must also possess virtue along with knowledge and skills; thus, ethics, knowledge, and wisdom are intertwined.
Ancient Hindu texts describe with surprising clarity and detail the pathogenic factors of the mind and the body and how they can be addressed via the four elements of therapeutics: physician, medicament, nurse (attendant), and patient. Each of the four elements is critical and the patient is expected to play an active role in recovery. The role of nursing is to serve the patient well through knowledge of nursing, dexterity, affection, and purity and by promoting patients’ and families’ participation in care. Decisions related to health and healing are based on a collective orientation and influenced by many contextual factors, including the stage of life of the patient and perceptions of one’s duty and righteous actions.
By drawing on the ancient texts and our own experiences, we have proposed some ideas on how Hindu religious beliefs might influence the understanding of health, illness, and care, for nurses as well as patients. We hope the discussion serves to explicate aspects of spirituality as the essence of humanity. Our intention is to provide insight and ideas for consideration, discussion, and further exploration. The degree to which any of the ideas presented would resonate in specific situations and with specific patients is difficult to anticipate, as the ways in which individuals adhere to and interpret the religious principles is subject to considerable variation.
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2. Das, Shukayak N. “Why do Hindus Have so Many Gods?” Hinduism Web. 14 July 2010. http://hinduism.about.com/cs/basics/a/aa072103a.htm.
3. Dhavamony, M. Hindu Spirituality. Rome: Editrice Pontificia Università Gregoriana, 1999. 11.
4. Whitman, Sarah M. “Pain and Suffering as Viewed by the Hindu Religion.” The Journal of Pain 8.8 (2007): 607–13.
5. Ibid., 607–13.
6. Srivastava, Bhartendu. The Bhagavad Gita: Its Comprehension and Recitation. Toronto: Pustak Bharti, 2010. 60.
7. Singh, B. Hinduism and Western Thought. New Delhi: Arnold Publishers, 1991. 29.
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9. Narayanasamy, Aru. “A Review of Spirituality as Applied to Nursing.” International Journal of Nursing Studies 36 (1999): 117–125.
10. Rigved 1/164/38.
11. Srivastava 45.
12. Sharma, R. K. and Bhagwan Dash. Agnivesas Caraka Samhita. Vol. 1. Varanasi: Chowkhamba Sanskrit Series Office, 1976. xxxiii.
13. Prabhavananda, Swami. The Spiritual Heritage of India. 3rd ed. Hollywood: Vedanta Press, 1980. 201.
14. Pomerans, A. J. Ancient and Medieval Science. New York: Basic Books, 1963. 155.
15. Sharma and Dash 19.
16. Jayram, V. “The Triple Gunas, Sattva, Rajas, and Tamas.” Hindu Website, 12 July 2010.
17. Murthy, N. A. and P. Pandey. Ayurvedic Cure for Common Diseases. New Delhi: Orient Paperbacks, 1997. 15.
18. Donahue, Patricia M. Nursing: The Finest Art. St Louis: CV Mosby, 1985. 58.
19. Dock, Lavinia L. A Short History of Nursing. New York: Putnam, 1920. 25.
20. Ibid., 62.
21. Donahue 61.
22. __________. “Humorism.” Academic Dictionaries and Encyclopedias Website, 29 Sept. 2010.
23. Crawford, S. Cromwell. Hindu Bioethics for the Twenty-first Century. Albany, New York: State University of New York Press, 2003. 40–44.
24. Sharma and Dash 43.
25. Crawford 78.
26. Sharma and Dash 44.
27. Sharma and Dash 45.
28. Crawford 78.
29. Crawford 78.
30. Dock 27.
31. Sharma and Dash 183.
32. Sharma and Dash 9.
33. Das, Shukayak N. “Hindu Astrology I.” A Hindu Primer 2007. 12 July 2010. http://www.sanskrit.org/www/Hindu%20Primer/hinduastrology1.html.
34. Crawford 68.
35. Coward 10.
36. Ibid., 11.
37. Sharma and Dash 187.
38. Donahue 62.
39. Sharma and Dash 187.
40. Donahue 62.
41. Sharma and Dash 290.
42. Dock 28.
43. Donahue 62.
44. Dock 306.
45. Joshi, Saraswati. Personal Interview. 25 July 2010.
46. Srivastava, Bhartendu. Ramas Glory. Toronto: Lugus Publications, 1998. xiii.
47. Hebbar, Neria Harish. “Ethics of Hinduism.” Hinduism 2010. 12 July 2010. http://www.scribd.com/doc/45090568/Ethics-of-Hinduism.
48. Ramakrishna, Swami Nikhilananda. “An Essay on Hindu Ethics.” Understanding Hinduism. New York: Vivekananda Center, 12 July 2010.
49. Crawford 13.
50. Crawford 19.
51. Crawford 20.
52. Sharma and Dash 227.
53. Ramakrishna.
54. Ramakrishna.
55. Crawford 22.
56. Whitman 607–13.
57. Whitman 607–13.
58. Crawford 106.
59. Narayanasamy 117–25.
60. Mysorekar, U. “Eye on Religion: Clinicians and Hinduism.” Southern Medical Journal 99.4 (2006): 441.
61. Crawford 29.
62. Crawford 15.
63. Crawford 197.
64. Crawford 197.
65. Crawford 198.
66. Narayanasamy 117–25.
67. Sen, Purnima. Personal Interview. 10 June 2010.
68. Crawford 106.
69. Paley, John, Helen L. Cheyne, Len Dalgleish, Edward A. S. Duncan, Catherine A. “Nursing’s Ways of Knowing and Dual Process Theories of Cognition.” Journal of Advanced Nursing 60.6 (2007): 692–01.
70. Rycroft-Malone, Jo, Kate Seers, Angie Titchen, Gill Harvey, Alison Kitson, Brendan McCormack. “What Counts as Evidence in Evidence-Based Practice?” Journal of Advanced Nursing 47.1 (2004): 81–90.
71. Crawford 85.