Imagine you’re about to undergo surgery. After asking about allergies, medications, and previous illnesses, the anaesthetist suddenly asks, “What is your caste or community?” For many patients, the question feels surprising, uncomfortable, or even inappropriate. Yet, in some hospitals, particularly in parts of southern India, this question has traditionally been asked for a medical reason rather than a social one.
The concern is a rare inherited condition called pseudocholinesterase deficiency, a genetic disorder that affects how the body breaks down certain anaesthetic drugs. While the practice has good clinical intentions, it has also become the subject of growing debate in modern medicine, where many experts question whether ancestry-based assumptions still have a place in patient care.
During general anaesthesia, doctors often use a fast-acting muscle relaxant called succinylcholine (also known as Scoline). Think of it as temporarily pressing the body’s “pause button.” It relaxes the muscles within seconds, making it easier and safer to insert a breathing tube into the windpipe before surgery. In most people, an enzyme in the blood called pseudocholinesterase quickly breaks down the drug, allowing its effects to wear off within a few minutes. But in people with pseudocholinesterase deficiency, this enzyme is missing or works poorly. As a result, the drug lingers in the body far longer than expected. Although the patient is unconscious during surgery, they may remain completely paralyzed for several hours afterward and be unable to breathe on their own.
In such cases, doctors must keep the patient on a ventilator in the intensive care unit until the drug naturally wears off. The condition is rare but potentially life-threatening if it is not recognized in time.
So why ask about caste? The answer lies in population genetics, not social identity. For generations, many communities in India traditionally married within their own groups, a practice known as endogamy. Over centuries, this increased the frequency of certain inherited genetic variants within specific populations, a phenomenon known as the founder effect. Studies have reported that pseudocholinesterase deficiency is more common in some communities, including the Arya Vysya community and certain Chettiar subgroups, than in the general population. Because of this, some anaesthetists have historically used community background as a quick bedside clue to estimate whether a patient might be at higher risk and, if necessary, choose alternative muscle relaxants that do not depend on the pseudocholinesterase enzyme. In this context, the question is intended as a medical risk assessment rather than a social judgment.
| “Good medicine asks questions to save lives, not to define people. The future of healthcare lies in replacing assumptions with evidence and tradition with precision.” |
However, medicine is evolving, and so is this practice. Many clinicians argue that relying on caste or community is increasingly outdated because modern India has far more inter-community marriages, making ancestry a poor predictor of an individual’s genetics. Others point out that asking about caste can make patients uncomfortable and may unintentionally reinforce social divisions. Today, safer alternatives to succinylcholine are widely available for many procedures, and laboratory tests can directly measure pseudocholinesterase enzyme activity when the condition is suspected or there is a family history. As the saying goes, “it’s better to measure than to guess.” Increasingly, experts believe that medical decisions should be based on objective evidence rather than social labels. The discussion ultimately reflects a broader shift toward precision medicine, where treatment is guided by each patient’s unique biology instead of assumptions based on ancestry. The goal remains the same as always: keeping patients safe while ensuring that healthcare is both scientifically sound and socially respectful.
