DISCUSSION MEDICAL HUMANITIES
Healthcare the Ayurvedic way
Ayurveda, the indigenous medical system of India, has integrated the concept of interconnectedness into its understanding of health and disease. It considers the human body as an indivisible whole with a network of interrelated functions, mind and consciousness, wherein a disturbance in one part will have repercussions in other parts as well. The key to health is for these factors to maintain stability since disease is seen as a perturbation in this network. Ayurvedic treatment aims not only at removal of disease, but also at the restoration of the equilibrium of bodily functions.
The centuries-old science of Ayurveda, apart from being a holistic form of medicine, also clearly defines the student-teacher and doctor-patient relationship. It sets high ethical standards of professional and personal integrity for the doctor, teacher and student. In addition to being technically skilled and well-read in the science, practitioners of Ayurveda must be compassionate and empathetic. Students of Ayurveda are taught the importance of compassionate caring for patients and maintaining personal integrity.
The societal impact of ill health is on the rise, with some diseases affecting not only the health of individuals but also that of a nation’s economy with their increasing healthcare costs (1). There is a growing consensus that the current system of healthcare should shift from its ‘technology, doctor and hospital-oriented’ approach to a more patient-oriented system (2, 3, 4). It is also being realised by a population weary of synthetic chemicals (5, 6) that conventional western medicine alone cannot handle the mushrooming of diseases, underscoring the need to widen the scope of healthcare to include alternative medical systems. All these inevitably bring into focus the patient-centric traditional healthcare medical systems like Ayurveda. The growing interest in Ayurveda is not only because it is free of synthetic chemicals, but also because of its integrated approach to health and disease (7). This article, while outlining the perspective of Ayurveda, also seeks to highlight how it approaches the patient as a complex and complete human being, addresses health and disease from a larger perspective, and empowers people to be responsible for their own health. The article also briefly outlines medical ethics as enshrined in Ayurveda.
Functional and systems perspective of Ayurveda
In Ayurveda, the perception of the human body differs significantly from that of western medicine. The former looks beyond structural reductionism and considers health as a complex interrelationship between body and mind, reflected at all levels. In Ayurveda, an organism is viewed as a system of relationships defining functions which are manifested through structures. Although a number of theories contribute to Ayurveda, the theory of dosha (vata, pitta and kapha – together constituting dosha) is an undercurrent felt throughout the Ayurvedic understanding of health, ill-health and treatment of disease. The words vata, pitta and kapha in Sanskrit, the language of Ayurveda, refer to functions like movement, transformation, support and growth, respectively, and a set of physico-chemical, physiological and psychological parameters contributing to these functions (8). A function is an emergent property of many contributing factors from structures and biochemicals, to physiological and psychological activities. A functional viewpoint will, therefore, be inclusive, taking into account all factors contributing to the function.
Health and disease in Ayurveda
Ayurveda considers the human being as a combination of two basic elements: consciousness (chetana) and inert matter (jada). The relationship between these two entities makes a human being. The realms within, therefore, consist of not only the physical and physiological aspects, but also the mind and subtler levels of awareness/consciousness. Ayurveda connects these realms and adopts a comprehensive view of life and health. It says that the subtler levels within influence the physiology. Susruta defines a healthy individual as (9):
In essence, “a healthy person is one whose dosha, dhatu(structural entities) and metabolic end products are in equilibrium. Further, there must also be clarity in consciousness, senses and mind for a healthy state.”
Health is that state in which the functions and parameters under the tridosha (vata, pittaand kapha), exist in fine balance; and disease occurs when there is an imbalance in these. Dosha,thus, represents a different perspective of the human body and provides a conceptual framework very different from that of western medicine. Ayurveda does not adopt a structural view like that of western medicine, but considers life as a complex and dynamic interaction of various functions and parameters, thus giving it a distinct approach in dealing with the human body in an integrated and holistic way. Everything from medicines and diet to mental, physical and emotional activities, and even seasons are classified and understood in terms of the changes they cause in the dosha,i.e. various functions and parameters in the body (10).
Approach to treatment in Ayurveda
Ayurveda provides a number of synonyms for the word ‘cikitsa’, explaining in depth what it means – treatment, which aims at the removal of the disease-causing factors and the restoration of the equilibrium of bodily functions and tissues (doshas and dhatus) in a way which is compatible, conducive and nourishing to patients without weakening them (11). This is an important distinction from western medicine, where the benefits from treatment are quite often outnumbered by its side effects (12, 13, 14, 15). Once the disease-causing dosha is identified, the entire treatment is planned to restore the deranged functions to balance using a variety of treatment modalities from medicines, medical procedures (panchakarma), and diet, to activities, mental and physical. For example, in osteoarthritis (vata disorder), the entire treatment will be directed towards reducing the increased vata (particularly the parameter ‘dryness’) i.e., use of ‘vata alleviating’ medicines, procedures (eg. medicated-oil application), diet and lifestyle activities. This shows how Ayurvedic multimodal treatment strategies restore the complex dosha / functional balance. Since interconnections between various functions (dosha) are known in Ayurveda, the treatment is able to avoid side effects by a judicious combination of medicines, diet and activities.
Ayurveda also empowers a person by taking health into the realm of one’s personal responsibility. The following example highlights this point: this is the case of a 45 year old patient, who had heavy bouts of cough and cold every spring season for nearly six years, and was on antibiotics during the affected period. From an Ayurvedic point of view, this kapha-related problem was diagnosed as a seasonal disease, with the root cause being indulgence in diet and lifestyle incompatible with the spring season. During spring, kapha gets aggravated and hence all kapha-aggravating food, such as citrus fruits, fruit juices and yoghurt, as well as activities like sleeping during the day, should be avoided. The patient, however, had been indulging in all these. The problem was addressed simply by correcting the diet and activities. The patient has now faced three spring seasons without any recurrence, after this intervention in diet and lifestyle alone.
Ayurveda, thus, offers several methods to stay healthy and prevent disease. This is in contrast to western medicine, where patients are completely dependent on doctors for treatment. In Ayurveda, people are taught to be responsible for their own health, rather than to consider themselves victims of disease factors beyond their control. Ayurveda, thus, is a complete healthcare system going beyond treating disease. Ayurvedic principles and methods of healthy living can easily be incorporated into people’s day to day lives, food habits and activities. This gives a whole new perspective on healthcare where one does not wait for people to contract a disease. The primary purpose of healthcare should be to keep people healthy and minimise the onset of disease.
The doctor-patient relationship in Ayurveda
The doctor-patient relationship is an important part of medical care and more so in the current health scenario where an increasing number of health problems are considered psychosomatic in nature, or diet and lifestyle-related. In Ayurveda, the doctor is considered not only as a healer, but also a friend and philosopher, and is expected to preserve a high level of professional and personal integrity to be in a position to advise patients. The doctor is constantly reminded that this noble profession is for the welfare of the patient and not for making money. The relationship between the physician and the patient is considered a key factor for the well being and recovery of the patient (16, 16a). Clinical empathy is considered an essential interpersonal skill required for professional competency, success and the patient’s well being. The doctor, in addition to being knowledgeable and technically skilled, is expected to maintain good qualities such as being compassionate, empathetic, caring and kind to all patients (16b). They are asked to nurture cordial feelings towards their patients like a mother, father, or brother (16c). The quality of compassion is highly valued and applied not only to patients but to all sentient life. This is an essential requirement for an Ayurvedic physician and forms an important part of medical ethics. Interestingly, truth is not to be viewed in isolation in Ayurveda. If it is likely to harm the patient, then compassion has to overrule this virtue. Likewise, if a lie can do good to the patient, it is to be condoned (17).
Medical ethics in classical Ayurveda
The Ayurvedic physician is entrusted with both the physical and mental well-being of the individual and the community, is considered the most important factor for successful treatment, and is expected to maintain a high level of personal and professional integrity when dealing with patients (16d). The code of ethics embodied in Ayurveda sets out the criteria for good physicians, teachers and medical students. Compassion, integrity, respect, honesty, courage and conscientiousness are considered the cornerstone of medical ethics. There is emphasis on the doctor’s need to transcend the needs of the physical body and connect to the self of the patient. In order to evolve to this state, the physician has to lead a life of integrity and renounce material wealth (16c). Ethics is taught not merely for its own sake but because it is considered essential on the path to the final goal in life. The same is conveyed to the patients as well.
Qualities of teachers, physicians and students
The teacher should
- be compassionate, noble by nature, honest, of a thoughtful disposition, courageous, intelligent, endowed with power of judgement and possess sharp memory;
- have self control, excellent character and devotion to patients, thorough knowledge of the medical and other allied sciences, good communication skills and be ready to share knowledge without reservation;
- be experienced, without malice or a wrathful disposition, compassionate towards those who approach him for being taught, well-disposed towards students and eager to teach them;
- have experienced self realisation to teach the essentials of a true human being to the students.
The Ayurvedic texts repeatedly say ‘He who practices medicine while holding compassion for all creatures as the highest religion is one who has fulfilled his mission and obtains supreme happiness’; ‘Those who make a trade of medicine for the sake of making a living, bargain for a dust-heap, letting go a heap of gold’; ‘He who practices medicine out of compassion for all creatures rather than for gain or for gratification of the senses surpasses all’. The texts say that patients trust their physicians completely and hence a physician should take as much care of every patient as he would of his own family (16, 17).
The student should
- be compassionate, intelligent, hard working, eager to learn and improve, and have respect for teachers
- have self control, purity in conduct and thought, and be honest.
Students are trained in the skills of observation, reflection, analysis and understanding of the science, the self and others. Formal training is considered an essential requirement to be a physician. However, it is only with years of practice, observation and constant study that a physician can aspire to be worthy of the profession. Students are advised that as physicians, they should never share information about a patient with others (17a). It is pertinent to note that these values have not only current relevance but also universal applicability.
As the world faces increasing chronic, psychosomatic stress and lifestyle-related disorders, medical scientists are beginning to realise the importance of an integrated approach to health and healthcare. Ayurveda, with its holistic perspective and integrated approach to health and disease, emphasis on diet and lifestyle activities, and time-tested clinical practices can play an important role in healthcare, especially in India. The experience and expertise accumulated in Ayurveda over several millennia should be used to benefit suffering people.
- Avenell A, Broom J, Brown TJ, Poobalan A, Aucott L, Stearns SC, Smith WC, Jung RT, Campbell MK, Grant AM. . Systematic review of the long term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technol Assess. 2004 May;8(21):iii-iv,1-182.
- Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof. 2004 Sep;27(3):237-51.
- Shanafelt TD, Bowen DA, Venkat C, Slager SL, Zent CS, Kay NE, Renalda M, Tun H, Sloan JA, Call TG. The physician-patient relationship and quality of life: lessons from chronic lymphocytic leukemia. Leuk Res.2009 Feb;33(2):263-70.
- Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physician’s empathy and clinical outcomes for diabetic patients. Acad Med. 2011 Mar;86(3):359-64.
- Wade C, Chao M, Kronenberg F, Cushman L, Kalmuss D. Medical pluralism among American women: results of a national survey. J Womens Health (Larchmt).2008 Jun:17(5): 829-40.
- Bishop FL, Lewith GT. Who uses CAM? A narrative review of demographic characteristics and health factors associated with CAM use. Evid Based Complement Alternat Med. 2010 Mar;7(1): 11-28.
- Jayasundar R. Quantum logic in Ayurveda. In: Morandi A, editor. An integrated model of health and well-being. From Indian tradition to globalized knowledge. Springer-Verlag. Forthcoming.
- Jayasundar R. Ayurveda: a distinctive approach to health and disease. Curr Sci. 2010;98:908-14.
- Sharma PV, translator. Susruta Samhita (Vol 1). Varanasi: Chaukhamba Visvabharati, 2004.
- Jayasundar R. Contrasting approaches to health and disease – Ayurveda and biomedicine. In: Sujata V, Abraham L, editors. Medicine, state and society – indigenous medicine and medical pluralism in contemporary India. Delhi: Orient Longman: 2012.
- Sharma RK, Dash B, translators. CarakaSamhita (Vol 3), Chaukhamba Sanskrit Series Office, Varanasi (2001). Chapter 1, verses 1-3.
- Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1995 Apr 15;279(15):1200-5.
- Moore TJ, Psaty BM, Furberg CD. Time to act on drug safety. JAMA. 1998 May 20; 279(19):1571-3.
- Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, Seger DL, Shu K, Federico F., Leape LL, Bates DW. Adverse drug events in ambulatory care. N Engl J Med 2003. Apr 17;348(16):1556-64.
- Dean C. Death by modern medicine. New York: Ash Tree Publishing; 2005.
- Sharma RK, Dash B, translators. CarakaSamhita (Vol 1). Varanasi: Chaukhamba Sanskrit Series Office; 2008.
- Sharma RK, Dash B, translators. CarakaSamhita (Vol 2). Varanasi: Chaukhamba Sanskrit Series Office; 2008. Chapter 8: verse 4.
16a. Chapter 9: verse 26.
16b. Chapter 1: verses 132, 133.
16c. Chapter 29: verses 6,7,13.
16d. Chapter 9: verses 6, 10-14, 21-23.
17a. Chapter 8: verses 5, 8, 13-14.