Bioethics, which is the title of this national conference, is a term that implies far more than medical ethics which dominates its sessions. What is bioethics? It is no more and no less than the ethics of living or ethics of life, which evolved from non-life over millions of years. Humans are a product of the evolutionary process like all other species, but they are unique insofar as they not only participate in the evolutionary process but also command and determine the future, as brought home so vividly by global warning. Nevertheless, as Professor Hubert Markl remarked, there is a circular relationship between nature and humankind because human concepts are nature’s concepts. Human technological and economic inventiveness is no more than nature’s way of acting upon itself and shaping its own future. The outcome could be glorious success or disastrous failure – in either case, nature acting through humankind bears partial responsibility for the outcome. This is fundamentally an ethical question. Are we right, for example, to cause the profoundest changes in biodiversity in all the 3 billion years of evolution by the mindless destruction of all living species to accommodate 10 billion human beings and their domesticated slave species of animals and plants? To make a sustainable future, we have an obligation to act in accordance with the dictates of reason and moral norms, and remain responsible for what we do. It is this undoubted fact of nature that makes us look for guidance to bioethics, without which life would be replaced by fossils. I would, therefore, compliment the organisers for placing the deliberations of this conference against the austere background of bioethics.

A missing domain

The programme of the conference is wide-ranging and covers practically all the vital and contemporary issues relating to medical ethics in India. However it is silent on one issue of great importance, which is ethics in the practice of ayurveda. An Indian traditional system of medicine par excellence, ayurvedic practices were in vogue in Buddha’s period when Takshasila was already reputed as a major centre for the training of physicians. The term “ayurveda” crystallised in the first century when the Charaka Samhita was written – a text that is taught even today in ayurvedic colleges. India produces over 15,000 ayurvedic doctors every year from over 200 colleges and, according to some estimates, 60 per cent of the countryside depends more or less on ayurvedic practitioners for basic healthcare needs. To survive and flourish even after 2,000 years of varied fortunes, the traditional system must surely have intellectual and ethical vitality, and its claim to consideration in a national discussion on bioethics would seem self-evident. An effort is necessary – however difficult and time-consuming it may be – to develop a unified ethical code that would apply to all forms of healing in India.

Ethics in ayurveda

In the three classic tests of Charaka, Sushruta and Vagbhata there are no separate sections on ethics. But ethical concepts are ever-present and an ethical undercurrent runs through all the texts. To distil the ethical content from these large texts is as difficult as extracting sugar from a cup of sweetened milk. One can only attempt to present gleanings from here and there to give a flavour of the ethical spirit which animates ayurveda.

Bioethics and ayurveda

On human beings as part of nature; their lives in harmony with nature; the kinship with all forms of life and so on, ayurveda has plenty to say. Consider the panchabhuta doctrine, so central to ayurveda: it says that the universe consists of five elements that are the stuff of the stars, earth, oceans, all living beings and everything that exists. These are, of course, not the elements of the periodic table, but substances that are perceived by the five senses of sight, hearing, taste, smell and touch. The sensory experience constitutes the basis of physical reality or nature – what is extrasensory may or may not exist, but that is not part of nature. According to ayurveda what exists in the human body exists in nature and vice versa, and their interpenetration and interaction are constant and continuous. The homology between the universal macrocosm and human microcosm was carried to extraordinary lengths until humans were regarded as cosmic resonators. Hurting nature was no different from harming oneself, and reverence for nature was ingrained in the practice of medicine.

Health and disease

Ayurveda laid a great deal of stress on good health and its maintenance, even as it laid out its elaborate encyclopaedia on diseases and their management. Health was regarded as a state of equilibrium that was sustained by a number of component equilibria. These included the equilibrium of the tissues of the body; of doshas or functional units; of fires that burn in the tissues and bring about changes such as food into tissues; of the body and its surroundings, and so on. The human body was designed to maintain this equilibrium, which was its natural state. Any deviation into disequilibrium, which we call disease, was largely brought on by one’s own misdeeds, and it could be counted upon to resolve and return to equilibrium automatically. All that the physician could do was to give a helping hand in the process. His task had less to do with the removal of a cause, which was, according to ayurveda, not the primary objective of treatment. Causes exist within the body and without, but they are not necessarily pathogenic. They become pathogenic only when the equilibrium is breached by the imprudent conduct of the individual. Nor is it possible to sanitise the body and environment of causes. Then why stress upon a cause to the exclusion of other considerations? Thus argued the ayurvedic texts.

Patients

Patients were seen in their homes or in the residence of the physician. Diagnosis was regarded as so important that an entire classical text – Madhava Nidana – was devoted to it. History was taken with great care not only from the patient, but also from his family and messengers who brought the summons. The illness of a person was, therefore, more than a matter between the patient and the physician. Having made the diagnosis, the physician had to decide whether the disease was treatable easily and curable; treatable with difficulty and palliative; or whether it was incurable and untreatable. He was obliged to inform the patient and family about the prognosis – especially the palliative and incurable types – before undertaking treatment. If a hazardous procedure such as the surgical removal of a bladder stone through the perineum was to be undertaken, the physician also had to obtain royal permission in advance. The Arthasastra of the third century BC had even prescribed capital punishment for physicians who undertook major procedures without prior permission that led to the death of the patient. The protocols for treatment specified the best of procedures and formulations that were apparently costly, and the physicians were exhorted to provide “no-frills” protocols for those who could not afford costly treatment. There was no bar on accepting fee for service except from specified categories such as the king, preceptor, Brahmins, the indigent, etc.

When necessary, patients were admitted to homes for treatment, which were described elaborately by Charaka. These had a scenic location with plenty of flora and fauna, lakes with clear water, rooms for the patient, physicians, attendants, kitchen, store, procedures, toilets, etc. The homes also had in residence storytellers, singers, and friends and relatives of the patients. It was obviously a friendly place. A physician was enjoined to look on the patient as his own so that he would develop total trust in him and regard him as his “father and mother” even in difficult circumstances.

The great emphasis laid on the signs and premonitions of impending death makes one wonder whether there existed in the remote past a class of physicians who specialised in the care of the dying, who were summoned when the treating physician felt that his role was over.

Training

Training of physicians took place in the gurukulas or in the universities such as Takshasila and Nalanda. The qualifications for the teacher and student were stringent, and covered physical, intellectual, professional, moral and social attainments and background. Students were preferred from Brahmin, Kshatriya and Vaisya castes, but Shudras were also admitted if the candidates were bright. On acceptance, the pupil had to take an oath administered by the preceptor in a sacred ceremony attended by a learned assembly. The oath covered the student’s conduct under all circumstances; his duties to the teacher, patients, friends, relatives, etc; his attitude to learning and practice of medicine; and his commitment to a virtuous life. The oath represents the high point of medical ethics in ancient India.

Professional conduct

The ancient texts reserved the harsh language of condemnation for the impostors and quacks who obviously existed even in those far-off days. Those who paraded their so-called skills and knowledge; who lacked proper training in theory and practice; who blamed the patient and relatives for setbacks; who fled if the patient developed dangerous complications; who made false claims about their lineage and achievements – all these came in for severe condemnation. The fraudulent physician was looked upon as a messenger of death. The noble physician who was virtuous, an expert in theory and practice, compassionate to the core and a friend of all was revered.

General conduct

The life pictured in the ayurvedic texts is that of a people who were happy and cheerful, and who sought to live for a hundred years in good health and comfort. They celebrated life and enjoyed themselves without worrying about metaphysical subtleties. These was little place for self-torture or renunciation, while respect was always shown to the saints. There was a general belief that diseases were caused by one’s own imprudent conduct or the act of gods. Virtuous conduct which stipulated the avoidance of the overuse, underuse and misuse of the 10 sense organs – sensory and motor – was prized because it was the sovereign prophylaxis for all ailments, which could even annul the effects of karma unless they were caused by enormously wicked actions. Truthfulness, compassion and reverence to learning were held in the highest esteem.

Conclusion

An effort to raise ethical awareness in health care should not be an event, but a never-ending process. The veneer of civilisation is thin and the atavistic tendencies of man for violence and cruelty are ever ready to burst forth, as happened in Nazi Germany. The cases reported by Beecher in the US reminded us that atavistic tendencies could reassert in more “civilised” ways under the garb of science. What can one say about India where people live in fear of their kidneys being stolen?

In strengthening our ethical convictions and practices, we are meeting our obligation to not only the present but also to our past and the future.