Abstract

The World Health Organization (WHO) in its Alma Ata Declaration, 1978, focuses on the development, promotion and recognition of the traditional medical systems. India has taken steps in this direction by recognising Unani medicine with other traditional medical systems practised in India. Presently, Government is promoting integration of the recognised traditional medical systems with conventional medicine at the national level, as an interdisciplinary approach to providing better patient-centred care.

Bioethics is a field of enquiry that examines ethical issues and dilemmas emerging from medical care and research involving humans. Although the term ‘bioethics’ was first mentioned in 1927 and later established as a distinct discipline in 1970s, the ethical principles in various contexts had been described centuries ago in the classical texts pertaining to traditional medical systems. Since ethics as a code of conduct was followed by ancient Unani physicians to safeguard the interests of humanity when providing healthcare, it was felt that a review of classical Unani manuscripts should be attempted to give an insight into codes of conduct described by various Unani physicians. In this paper, a 10th century book, “Kamilussanah” authored by Ali ibn Abbas al-Majoosi, also known as Majoosi (930-994 CE), is reviewed through the prism of ethics.

Introduction

Bioethics is a field of enquiry that examines ethical issues and dilemmas emerging from healthcare and research involving humans (1). The Unani system of medicine originated in Greece, based on the teachings of Hippocrates (460-370 BCE) and Galen (129-200 CE) and was further developed into an elaborate medical system by Arab scholarly practitioners, like Rhazes (865-925CE), Avicenna (980-1037CE), Al-Zahravi (936-1013CE), Ibne-Nafis (1210-1288 CE), and others. Thus, the Unani system was established in many countries, enriched further when passing through each region before it was introduced in India around the 8th century (2).

Hippocrates, the father of medicine, in his famous Hippocratic Oath enunciated the principle of beneficence to the patient, which became the foundation stone of medical ethics for all ages and generations (3). The Unani physicians followed the principles laid down by Hippocrates, not only in applying them to medical practice but also to medical ethics (3: p 8). This system was developed and given the status of a science in Greece, the roots of which can be traced back to its earlier originators in ancient Egypt and its sister civilisation Mesopotamia. It was later developed by the Arabs, nurtured by the Persians, and further established as modern day science in India (4). Since the introduction of the Unani system of medicine in India, the country’s continuous contributions to its further development have been globally recognised. So much so, that India is considered a world leader in Unani medicine with its robust infrastructure and well-regulated system of practice (5).

Pursuant to the Alma Ata Declaration of WHO in 1978, India has taken steps to integrate traditional systems including Unani medicine with conventional (modern/allopathic) medicine at the national level, and is undertaking collaboration among diverse health professionals as an interdisciplinary approach to provide better patient-centred care (6). Ayurveda, Yoga & Naturopathy, Unani, Siddha, Sowa Rigpa (Tibetan or Amchi medicine) and Homoeopathy (AYUSH) are the recognised traditional systems of India.

Currently, the Unani system of medicine, which is an essential part of the national healthcare system has its own recognised practitioners, hospitals, educational and research institutions (7). Providing treatment which is beneficial for the patient, while avoiding or preventing harm, is derived from the principle of respect for life which is an important key component for any medical practice, including that of traditional medicine, and falls within the domain of beneficence, a strong pillar of bioethics. Contextualisation of Unani medical ethics in the light of the existing classical literature is the need of the hour (8).

Many organisations – governmental and non-governmental – are actively engaged in research and development programmes. Furthermore, as per the WHO guidelines, clinical trials can be started from phase II human trials, if the relevant formulation is traditionally used for that condition. “The National Ethical Guidelines for Biomedical and Health Research involving Human Participants” issued by the Indian Council of Medical Research, in 2017, pertain to researchers in all systems of medicine (9: p 2).

Ethics is not a new concept in Unani medicine. It is mentioned in books like Kitab al Mukhtaraat fit Tibb where Ibn Habl Baghdadi (1122-1213 CE), an eminent Unani physician, has listed the characteristics of a Unani physician, emphasising his moral and ethical behaviour (10). A summary of bioethics in Unani medicine can be found in the second chapter of Kamilussanah (11: p 8-9), which is drawn from the views put forward by different Unani physicians, especially Hippocrates. Hence, we chose the ancient text, Kamilussanah, of the 10th century to focus on its perceptions of bioethics.

About Kamilussanah and its author

Kamilussanah was written by Ali ibn Abbas al-Majoosi (930-994 CE). He was a renowned physician of the 10th century CE, born in the Iranian city of Ahwaz. He dedicated this book to King Azduddaulah and named it Kitab al-Malaki (Book of the King). He carried out a critical evaluation of the works of the renowned physicians, Hippocrates (460-370BCE), Galen (129-200CE), and Rhazes (865-925CE); and tried to fill whatever lacunae he found in their writings in Kamilussanah. The Arabic text of Kamilussanah was published in 1282 H/ 1866 CE from Lahore, in 1294 H/1877 CE from Cairo, and reprinted in 2005 by CCRUM, New Delhi. The Urdu translation of Hakim Sayyid Ghulam Husnain Kanthuri was published in 1889 (12: Foreword).

Kamilussanah has two sections. The first volume consists of 10 tracts with 265 sections, and covers theoretical medicine, while the second volume also has 10 chapters consisting of 499 sections, and covers practical medicine. This book has been translated into many languages. It was fully translated into Latin by Stephen of Antioch in 1127 and it was printed in Venice in 1492 and Lyons in 1523 (13).

Bioethics in Kamilussanah

The author of Kamilussanah, inspired by the teachings of Hippocrates, has discussed bioethics in the second chapter of the first volume of the book (11 pp: 8-9). The immense importance given to ethics is indicated by the author’s placing it in the initial chapter, ensuring that the physician should be acquainted with ethics, before venturing deeper into the subject. Presented below are extracts from the chapter dealing with bioethics.

• On the physician’s attitude

  It is mentioned that ‘The physician should be god fearing’ and also “He should be knowledgeable and intellectual”. (11: Chap   2: p 8)

• On the student-teacher relationship

  The author says “The physician should respect his teachers who provided him with knowledge as he respects his parents. He   should provide them with his services readily and show good behaviour” and that “He should show affection and look after the   children of his teachers as his real brother/sister and should keep some share of his wealth for them”. (11: Chap 2: p 8)

• On the dissemination of knowledge

  Majoosi states that “Knowledge should be completely disseminated without hiding anything. It should be taught without any   conditions and without fees and students should be treated like you treat your children”. (11: Chap 2: p 8) “The physician   should develop the habit of taking rounds in hospitals and clinics”. “He should discuss with his teacher about the patients and   the knowledge gained from medical texts”. (11: Chap 2 p 9). This is to encourage an all-inclusive dialogue between teacher   and student even after he has qualified as a physician.

• On the quality of students enrolled

  The author emphasises that “Ashraar people (people in whom the right attitude is not developed) who cannot do justice to this   system should not learn this knowledge”. (11: Chap 2: p 8)

• On the quality of the physician’s treating modality

  The author says “He should fully justify the treatment of the patient with drugs, diet and regimen therapy” and “His aim should   not be to earn money but serving the humanity for the goodwill of God”. (11: Chap 2: p 8)

• On the use of toxic drugs by physicians

  It is mentioned that “He should not administer a toxic drug to any human nor should the information regarding such toxic    drugs and their usage be disclosed to anyone”. “Abortifacient drugs should not be given nor should information regarding this    be leaked”. (11: Chap 2: p 8)

• On maintaining secrecy and confidentiality

  It is stated that “He should be able to keep secrets of the patients and maintain confidentiality regarding treatment and should   not disclose it to anyone near or far related person to the patients”. (11: Chap 2 p 8)

• On the conduct of the physician

  The physician has been asked to abstain and from all ill deeds whether physical, mental or social (11: Chap 2:p 8). It is also   mentioned that “He should be spiritual, religious with good manners, soft spoken and should behave with the patients in best   possible manner”. (11: Chap 2: p 8); and that: “The physician should not indulge in excessive pleasure, luxurious and leisurely   life, use intoxicants and be lazy” (11: Chap 2: p 8)

• On the orientation and updating of the physician’s knowledge

  Majoosi recommends that “He should often consult books and add to his knowledge from different sources.” (11: Chap 2: p 8)

• On dealing with female patients

  It is advised that “He should take extra precautions while treating females and should not look at them with bad intentions”.   (11: Chap 2: p 8)

• On dealing with vulnerable populations

  There is specific mention of vulnerable populations in that “He should be able to do justice to vulnerable population and    readily treat them without hesitation”. (11: Chap 2: p 8)

Most of the ethical principles listed in this book are compatible with the Declaration of Geneva of the World Medical Association which binds the physician with the words, “The health of my patient will be my first consideration,” and the International Code of Medical Ethics which declares that, “A physician shall act in the patient’s best interest when providing medical care” (14).

Majoosi has elaborated on the notion of Primum non nocere (Do no harm) the principle attributed to Hippocrates. Emphasis is laid on the character of the physician and his moral and ethical behaviour towards the patient. The physician should ensure that no harm is done with the use of toxic and abortifacient drugs to any human being, and should maintain confidentiality. He is reminded of the need to keep himself abreast of the latest medical knowledge and encourage discussions with his colleagues. In the present context, the description of bioethics by Majoosi may be co-related to the bioethics principles of beneficence and non-maleficence.

Current regulations of ethics in Unani medicine in India

Currently, the AYUSH systems, including the Unani system, are regulated by the standards of professional conduct, etiquette and code of ethics laid down by the the Central Council of Indian Medicine (CCIM). These are to be observed by all practitioners of AYUSH systems who have to give an undertaking to abide by the code of ethics prescribed by the Council in 1982 (15). Here too, emphasis is laid on the character of the physician, and the duties of a practitioner towards his patients. The practitioner is encouraged to increase his knowledge. These regulations more or less cover the aspects covered by Majoosi. The current regulations pay more attention to professional conduct and etiquette, duties and obligations of practitioners of Indian medicine towards patients and the public at large. However, for clinical research, the guidelines laid down by the Indian Council for Medical Research (ICMR) including reporting of serious adverse events, and compensation and AYUSH GCP guidelines are to be followed by AYUSH researchers. (9: p 84)

Description of ethics in Kamilussanah and its relevance to the Hippocratic Oath and current regulations

The Hippocratic Oath has been considered the gold standard for the conduct and behaviour of a physician from an ethical perspective. The oath emphasises that a physician should treat the patient to the best of their ability and judgement. While the importance of beneficence is stated in detail, the patient’s autonomy has not been discussed or listed specifically in the book under review. Justice, as mentioned by Majoosi, is about providing just treatment to vulnerable populations, which is not the same as the notion of “justice” in current ethical principles as applied to research. Utmost importance was however given to the conduct of a physician in a clinical setting which covered moral, ethical and social conduct.

The Hippocratic Oath focuses primarily on the connection between the patient, the physician and the relevant illness. The writings of Majoosi, mainly based on the teachings of Hippocrates and other eminent Unani physicians, cover the principles of beneficence, confidentiality, humility and morality (16).

However, the description of moral and ethical behaviour of a physician in Kamilussanah is comparable to the Declaration of Geneva of the World Medical Association (WMA) and the International Code of Medical Ethics and it is also comparable to the clauses of the Standards of Professional Conduct, Etiquette and Code of Ethics for practitioners of Indian medicine as laid down by CCIM, which makes it mandatory for each registered practitioner to make a formal declaration to abide by that Code within 30 days of registration. The clauses on character, duties, responsibility of practitioners of Indian medicine towards patients and the public, and also towards other practitioners listed in the code of ethics by CCIM had already been established by Majoosi in this book. Moreover, the special mention of vulnerable population by Majoosi shows his understanding of ethical issues pertaining to such populations because of the possibility of their either being denied treatment or being given inappropriate treatment, due to cost and other factors. It is a fact that even today this situation continues and modern bioethics principles emphasise the need for safeguards against such malpractices.

Conclusion

It is clear that Ali ‘ibn Abbas al-Majoosi in his book Kamilussanah, based on the teachings of Hippocrates and other eminent Unani physicians, laid down a code of medical ethics for a practising physician, to be followed right from the time of enrolment as a student. The duties and obligations of physicians towards patients and professional colleagues, including doing no harm, providing the best possible care, being respectful, maintaining confidentiality, have all been emphasised. Equal importance has been given to the physician’s moral character, the need for patience and graciousness, and the need for updating one’s knowledge. One must keep in mind that whatever Majoosi has outlined has emerged from the ethics of medical practice in his lifetime, and does not address specific ethical issues which have arisen in present day medical practice and research.

The Unani system of medicine has a rich heritage of classical literature and for the present project, Kamilussanah, a book of the 10th century CE, was reviewed for its perspectives on bioethics. These ethical principles can be used to formulate guidelines for researchers and practitioners in the Unani system, all over the world, maintaining its traditional context. Similarly, other Unani classical texts could be reviewed, and a combined code of conduct, based on classical literature contextualised for the present times could be generated for inclusion in the present teaching curriculum, alongside the current regulatory “Standards of Professional Conduct, Etiquette and Code of Ethics” put in place by CCIM.

Acknowledgements: Our sincere thanks to the Indian Council of Medical Research (ICMR) for organising a training programme, with a grant from the Fogarty Centre, NIH, USA, as the present paper is the outcome of that training. We acknowledge the late Dr. Abdul Hannan, Former Deputy Director, Regional Research Institute of Unani Medicine (RRIUM), New Delhi, for helping in the translation of the Arabic text mentioned in the book, Kamilussanah.

A statement of any submissions of very similar work: None declared.

Conflict of interest: None declared