“Confessions of an Ayurveda Professor”, by Kishor Patwardhan, published in IJME, has set the stage for heated discussions within and outside the medical circles. It uses primitive philosophical criteria to argue that Ayurvedic principles relating to anatomy and physiology are obsolete, and that they need to be removed from the syllabus. As Ayurveda students, we explore the counterview to this, pointing out the fallacies behind each point raised, and suggest solutions that we find suitable for effective, competency-based Ayurveda education.
Keywords: Ayurveda curriculum, physiology, defining science, selective scepticism, tridosha
The recent reflective article by Kishor Patwardhan, titled “Confessions of an Ayurveda professor” [1], in this journal, raises critical questions on the current relevance of Ayurvedic anatomy and physiology, as taught in the Ayurveda curriculum. The author’s concerns are genuine, intriguing and demand detailed discussion. As Ayurveda students, we find many of our concerns reflected in the manuscript. But the author’s reasons for the concerns, and their solutions seem biased, illogical, and detrimental to Ayurveda, hence this counter-perspective. Based on our training under preceptors who practised and preached Ayurveda as it is, we review the ideas raised in Dr Patwardhan’s article, and suggest solutions from a different perspective.
Attempts to corelate structures of Ayurveda with those of western medicine have rightly been pointed out as being in a state of crisis by Patwardhan. Though such half-baked attempts may sound convincing, they ultimately provide distorted images. The aim behind such strained interpretations seems to be the “superimposition of modern science over classical references” and the reason for their rejection, the absence of unanimity between them. But why should there be unanimity at all? Of course, western medicine is both state of the art, as well as the primary system of healthcare endorsed by the state. But this does not mean that any other stream of knowledge that is not compatible with it is ‘pseudoscience’.
Defining science has been a complicated affair. Philosophers like Paul Feyeraband and Ludwig Wittgenstein highlight the lack of uniformity among definitions of science [2]. Efforts have been made to demarcate science, traditional knowledge, and pseudoscience in terms of their origins, objectives, and systematicity [3]. The Science Council gives it a relatively comprehensive definition. Scientific methods include induction, objective observation (not mandatorily mathematical), experiments, resultant evidence, repeatability, and critical analysis [4]. Another defining characteristic of science is systematicity in claiming and establishing knowledge [3]. The definition does not mention a single science, but rather puts forward criteria that can be fulfilled by validating and systematising any knowledge, not necessarily dismantling its methods, or replacing it with modern scientific logic. Despite these facts, efforts to declare them invalid are the result of a predisposition, a selective scepticism [5].
Selective scepticism denotes the tendency to sceptically analyse one view while blindly following the other [6]. It originates from and leads to notions that only one view regarding a particular topic is valid. It is a phenomenon common to all domains, but its presence with regard to Ayurveda is disproportionately high. This scepticism has its roots in the formative phases of Ayurveda students. They start learning Ayurveda with underlying insecurities. They have been given elementary training in modern biology, physics, and chemistry, but are introduced to completely new, abstract concepts. Simultaneously, they learn evidence-based, easily perceivable western anatomy and physiology. These setbacks are coupled with the language barrier (Sanskrit), curricular handicaps, preceptor attitudes, and inter-preceptor contradictions. Altogether, these make the learning of the Ayurvedic body knowledge obscure and less interesting. Meanwhile, modern anatomy and physiology are privileged in all these aspects. Hence, they easily penetrate these cognitive layers of an Ayurveda student; so, it is no wonder they become followers of the same.
It is known that efforts to understand the human body have started from the same point in Western medicine and Ayurveda, ie, dissection of the human body (Herophilus and Erasistratus, Sushruta) [7]. Then how is one of them considered a state-of-the-art form, and the other obsolete? The difference in methods starts right from the process of dissection. The former followed the scalpel dissection method where the body was naturally or artificially embalmed and dissected using sharp instruments. In Ayurveda, a different method was followed, which some scholars term ‘hydro-dissection’ [8]. At this point, there are two constituents of knowledge: the object and the observer. Both the health systems have mentioned these components. In the former, the object was preferred for detailed study and decision-making, whereas in Ayurveda, the observer and his perceptions were the bases of inferences and algorithms (for diagnosis and management). Efforts are in progress to recreate the method of Sushruta and document its findings [8, 9].
Ayurveda preferred the identification of commonalities between structures and functions and utilised them to understand physiology, harmonious functioning of the body and mind, illnesses, and their treatment. This led to a convergence; the properties and functions that coexisted most frequently were grouped together (to reduce complexity and facilitate expression) and were named depending on the agents in nature resembling these functions. The tridosha concept is its culmination. In most Indian theistic philosophical schools, such variables are said to be “inferred” and they are considered existent (as they are felt through their effect on the manifest forms in the body). Such variables are termed “latent variables” in statistics. Reduction of complexity of data in statistics is also done using similar methods as in factor analysis [10]. In short, refuting the tridosha theory as it fails to coincide with any of the western anatomical structures is like refuting the earth’s axis as it could not be found even after excavation at both the poles!
Even in recent years, tridosha-based treatment strategies have helped Ayurveda effectively manage public health crises and novel diseases, and not western pharmacological actions. Chikungunya [11] and Covid-19 [12, 13, 14, 15] are documented examples. Any intervention requires an Ayurveda-based logic of selection and not just a western pharmacological substantiation of its action. Hence, these tools are indispensable in Ayurvedic education. Their being shunned and replaced with exclusively western physiological concepts will render Ayurveda’s practice redundant due to a logical mismatch.
In Ayurveda, there is no demarcation between structure and function (they were together called shaarira). This bifurcation was made later for academic purposes [16]. In most sciences, this perception of sharira was devised depending on the purpose for which the body was observed. It is different in acupuncture, yoga, and Ayurveda. Hence, the same object ― when viewed using different methods, with different objectives, by different individuals ― looks different.
Procedures in Ayurveda like vasti (a form of medicated enema) and nasya (nasal medication) and their medicines depend on the Ayurvedic shaarira for understanding their action, drug choices, and repurposing. Knowledge of western medicine can neither substantiate their action and indications, nor their selection of medicines, let alone their further use and repurposing. Systems like acupuncture still use their own system of anatomy and they would become irrelevant if their physiology is replaced.
Patwardhan in his article cites a view from another work [17], where its writer states that the tridosha theory necessitates the use of cooling therapy in disease characterised by heating, but the argument itself is erroneous. First, heating is a manifestation of fever, not a cause. The reason behind it is the displacement of heat by doshas and undigested matter from the stomach (the pathogenesis of fever) [18]. Second, hot water is advised in fever almost universally with specific exceptions that are manifested when the heat principle (pitta) is the cause. The writer also forges a story of genesis of tridoshas which is a random collection of contexts and lacks any logic of sequence and practicality.
Individualised prescriptions are an excuse to escape scrutiny, and in practice, represent not only poor scientific spirit, but also poor understanding of Ayurveda. Different prescriptions for the same clinical presentations in different patients are attributed to the common-sense principle that no two individuals are the same [19]. Elicitation of the bases of variation is a part of basic Ayurvedic clinical skill, mostly done through patient interrogation [18]. They are introduced into the syllabus in the early years (in basic principles) and reiterated further in clinical training. Ironically, such skills, not tridosha assessment, are considered in “Ayurvedic” surveys assessing the clinical competence of its students [20].
Indeed, Ayurveda has several obsolete components. It has kept renewing itself by replacing ideas that did not match observations, incorporating new pathogeneses and their management, new drugs, and deleting outdated, difficult-to-execute procedures (as in surgery and rejuvenation).
The linguistic intricacy of the Ayurvedic terms make them recondite to many. There are several herbs with obscure identity and poor availability. They are being replaced with apt, sustainable substitutes. Many diseases are no longer seen in our current society. Multiple procedures in toxicology, surgery, and neonatology are no longer recognised by the state. Research outcomes and technological advances must be included in the syllabus. The time is ripe for genuine revamping that resolves these crises. Students must be trained to appreciate both the streams of knowledge, while preserving their integrity and individuality. They must be competent in diagnosis and management using Ayurveda as well as western medicine.
Falsifiability is considered a crude, primitive tool to assess a theory due to its inability to incorporate probabilities, explain models (which replaced theories), and its poor applicability in most domains except physics [21]. Testing a theory for its validity and reliability is not linear, rather it includes the following sequence:
i. Testing it multiple times.
ii. Cross-checking it with the observations.
iii. If mismatch exists, confounders are looked for.
If there is a mismatch but no confounders, then the theory is rejected. If a confounder exists, they are excluded, and both are studied separately. Otherwise, the theory stands valid. For instance, the observed orbit of Uranus was not compatible with that predicted by Newton’s gravitational theory. This did not lead to abandonment of the theory, but confounders were searched for, which suggested the presence of another planet, (an ad hoc conjecture was added!) the motion of which exerted influence on the former (Adam and Le Verrier) [22]. This resulted in the discovery of Neptune, which would have been impossible otherwise.
Popper was either reluctant to admit or unclear about the difference between ad hoc and auxiliary hypotheses [23]. This has probably caused Patwardhan and his motivators to misconstrue the same. (Some scholars consider them as different grades of ad hoc hypotheses) [24]. They differ in the sense that an ad hoc conjecture does not have independent verifiability or logical consequences, whereas the latter has. In the author’s example, if individuals of pitta prakriti express hypertension contrary to the hypothesis that kapha prakriti individuals will have it, it can be subjected to further independent testing. The auxiliary conjecture proposed by the author in no way rescues the actual hypothesis, rather it suggests an alternative, independently verifiable mechanism that could have led to this observation.
Principles, especially those relating to anatomy and physiology are the identities of many systems of traditional, complementary, and alternative medicine including Ayurveda. While international bodies acknowledge their contribution to science and call for the preservation of their integrity [25], the aforementioned views warrant transplanting their practices from their original backgrounds to that of western science. The long-term outcome of these studies would be these knowledge systems ending up as suppliers of certain semi-effective, add-on, complementary biomolecules. The “confession” and the sources from which it draws inspiration demand the renouncing of Ayurvedic concepts, despite the experimental and observational evidence regarding their validity and reliability. Please leave that decision to those who have tried them.