Introduction

In the past century of medical history, innumerable policies, regulations and laws have been framed to promote and ensure ethical practice in all aspects of healthcare. Despite these measures, we are bombarded with reports of unethical medical practice and research misconduct with disturbing frequency. In the case of the few who are “caught”, the penalties are punitive and the transformation in attitude and behaviour, if any, is usually more cosmetic than real. Many instances of unethical behaviour arise not from ignorance, but from an attitude of deliberately overlooking norms and regulations. Regulators, institutions, educationists, policy-makers and activists often despair over what further steps need to be taken to promote a genuine and sustained moral attitude and behaviour. While we continue to harp on more strict regulations and better enforcement, have we been overlooking any other avenues that may exist?

At present, the teaching of medical ethics focuses chiefly on principles, guidelines, rules and laws. Medical ethics is understood as a list of do’s and don’ts and its practice is considered a matter of social and professional etiquette or a regulatory requirement. Even though many of the present ethical guidelines evolved from a sense of moral outrage at horrifying instances of human exploitation in the name of medical science, the philosophical foundation of these guidelines (ie an understanding of human beings, their purpose and inter-connectedness, and how they should behave towards one another) is not really evident to the casual reader of the regulations. Despite its commitment to ethics, medical decision-making is heavily influenced by the character of individuals and this, in turn, is shaped by the person’s environment, experiences and personal philosophy. For all these reasons, there is a need to reiterate the philosophical foundation of ethics.

Traditionally, the imperative for moral behaviour drew its strength from theistic beliefs. Since about the 17th century, more voices were heard in favour of basing moral behaviour on secular foundations. Immanuel Kant’s categorical imperatives (1) are clearly founded on a secular philosophy. At present, too, there is a popular trend of secularism, sometimes accompanied by a disregard for religion, and the theistic imperative for moral behaviour is losing ground. Despite the popularity of the secular trend, it appears that life is not really guided by the “secular philosophies.” The imperative for moral behaviour is largely dependent on personal resolve, fear of the law, or a social obligation to abide by regulations. It is well known how resolve can be weakened, the laws bent or regulations overlooked. While secular philosophies do offer scope for a categorical imperative, theistic approaches can enhance and enrich this scope. Therefore, it is worthwhile not only to revive the philosophical foundation of ethical behaviour, but also its theistic moorings.

Each religion has its own distinctive derivation of ethics and morality. There is extensive written material on the Christian, Jewish and Islamic philosophies in relation to medical ethics (2, 3, 4). However, there is meagre literature of this nature as far as Hinduism is concerned (5, 6, 7). Hindu philosophies are among the most ancient philosophies that are still flourishing and it would be interesting to see how they can contribute to present-day medical ethics.

This article dwells on some aspects of Hindu philosophies, particularly the concept of dharma. A seemingly elaborate account of Hindu philosophies is presented here. However, in actuality, it is only a succinct outline that is meant to provide the reader with a glimpse of the system of thought. Unless one provides a background that acquaints the reader with the depth of the philosophies, it would be difficult to make a meaningful connection to medical ethics.

What is Hindu philosophy?

The word “Hinduism” has been conventionally used to denote a religion. However, it is also an umbrella term for a way of life, guided by a wide variety of beliefs and rituals based on Vedic1 traditions. The Vedas and Upanishads are its foundational scriptures (8, 9). The term Hindu philosophy actually encompasses different schools of thought,2 of which Yoga and Vedanta retain their importance in the current practice of Hinduism. There are many apparent and subtle differences amongst these schools of thought, and it is difficult and problematic to comprehensively explain the terms associated with or variations between the philosophies in a short article like this. The various schools of thought are more or less in agreement that the purpose of human life is to strive for spiritual progress, towards moksha or nirvana (liberation) – be it liberation from “the cycle of birth and rebirth” or from “unhappiness and misery” – through an experience of oneness with God or the cosmic Self.

Goals of life: thepurusharthas

In Hinduism, life is considered to consist of four stages: Brahmacharya, Grihastha, Vanaprastha and Sanyasa3. During one’s passage through these stages, one has to fulfil certain goals to have led a meaningful life. These goals, known as the purusharthas, are dharma, artha, kama and moksha (10). The scriptures4 offer guidelines and instructions on how these goals can be attained. Most of the instructions are deontological in nature and have the tenor of categorical, moral imperatives.

In common parlance, dharma simply refers to a person’s religion. Dharma is commonly interpreted as rituals, duties, caste rules or even the law, but such interpretations are reductionist. In philosophical terms, dharma refers to a way of life that is aligned to the natural order of things. Natural order itself refers to an orderly system in nature that is believed to be divinely established, with the purpose of ensuring sustained maintenance of life, in a peaceful and harmonious manner. While dharma signifies actions that are aligned to the natural order of things, adharma would mean actions that are against this order. It is believed that only the pursuit of dharma can bring about social harmony and peace in the world. Adharma is believed to lead to suffering, conflict, discord and imbalance. Therefore, dharma is also simply referred to as righteous conduct.

Human beings are said to have certain duties or responsibilities during the four stages of life that must be carried out in such a way as to sustain the natural order.

Therefore, dharma means carrying out all one’s responsibilities, even while maintaining peace and harmony. The words “duty” and “responsibility” are used synonymously. Since the concept of dharma is part of a theistic philosophy, a person’s foremost responsibility is considered to be the expression of gratitude to God and to the teacher / guru. Second in importance is a set of responsibilities arising from the roles assumed in the family, ie that of a child, parent and grandparent. These responsibilities include providing care, sustenance, protection and love. The third set of responsibilities emanates from the premise that human beings are social beings and embedded in society. As they derive a great deal from society, they have a duty to give something back, to help others, serve those who are suffering, and promote peace and harmony in society. The final responsibility is towards nature, the environment and all forms of life.

Without material means, it would not be possible to carry out these responsibilities. Therefore, artha, the second goal, focuses on the need to earn material wealth as a means to abide by one’s dharma. The essence of how one should achieve this goal consists of earning wealth in a congenial manner, by virtue of one’s own efforts and hard work, without cheating, stealing, harming or causing loss to others, without being driven by greed, and without disturbing peace and harmony in society. Wealth should not be accumulated mindlessly; it should be accumulated only to the extent necessary for meeting one’s responsibilities.

Kama is commonly translated as “erotic love” or “sensual desire”. However, in the context of the purusharthas, it refers to the responsibility of love and of showing integrity in relationships. It extends to the responsibility of procreation, too. The experience of fulfilment and satiety must be at the emotional and psychic levels rather than the physical alone. Thus, kama signifies something more than sensual desire alone.

Mokshaindicates “liberation from the cycle of birth and rebirth”. Such liberation would be attained as a consequence of the fulfillment of the other three goals, extending across all the stages of life, and is the result of a cumulative effort over many births or lifetimes. In contemporary times, however, liberation has also been interpreted as “liberation from unhappiness and misery”. It seems difficult to actually describe or experience liberation from the cycle of birth and rebirth while it is possible to experience liberation from unhappiness.

The telos of dharma

An explanation of dharma is completely intelligible only if it also includes an account of its telos or purpose. Dharma focuses not merely on the action, but also on the purpose of the action and, in extrapolation, the purpose of human life. A lifetime of practising dharma allows a person to flourish and live the good life, which is somewhat similar to, though not exactly the same as, Aristotle’s eudaimonia (11). Today, people’s notions of the purpose of life and a good life are extremely varied and controversial. Aristotle’s eudaimonia entailed living well and taking part in activities that exercise the rational part of the psyche, while the purpose of life was to flourish. Eudaimonia was the “end” by itself. The parameters for proof of a good life were wealth, power, friends and beauty. In Hindu philosophy, a good life means performing activities that exercise the spiritual part of the psyche, while the purpose of life is to attain moksha and not merely to flourish. The parameters for proof of a good life are an “experience of peace, harmony and lack of misery” (10, 12).

The world as a cosmic family

Vedanta, in particular the Advaita version, sets forth the concept of cosmic unity in clear terms. This concept regards all living and non-living entities in the universe as one and the same, as mere expressions of the essence of the large cosmos (the Whole). According to Advaita (13, 14), the oneness can be experienced only when one thinks of oneself not as a separate individual entity, but as a being who is integrated with the whole cosmos; and moksha can be experienced only when this oneness is experienced. Therefore, submergence of the self into the Whole and abnegation of the sense of separateness or individuality is celebrated. This emphasis on cosmic unity has influenced several physicists and philosophers, such as Einstein, Schrodinger, Spinoza, Nietzche and Schophenhauer (15, 16, 17, 18). Besides influencing physicists’ understanding of the universe, Advaita has influenced the derivation of ethics in the Hindu ethos. According to Swami Vivekananda, “…this oneness is the rationale of all ethics and spirituality…the essence of all morality is to do good to others… whomsoever you hurt, you hurt yourself. They are all YOU….” (19). Also, “Only when one can see oneself in others, only then can one truly feel love and respect for others. The sense of universal brotherhood promoted by this philosophy is echoed in the Upanishads as vasudhaiva kutumbakam (the whole world is my family) (20).

Translating dharma into daily life

While abiding by dharma in brahmacharya (student life) – the first stage of life – one’s responsibility is to educate oneself, study and gain knowledge. The knowledge acquired should extend beyond technical information to a knowledge of the scriptures and philosophy. Emphasis is also laid on the practice of contemplation, as well as on efforts to understand the merits of a life of simplicity, self-discipline and the judicious use of resources. This stage is one of celibacy in thought, word and deed, so that the mind can remain focused on studying. The potential for ethical enrichment offered to a medical student, or for that matter, a student of any other health discipline, by the prescriptions of dharma is clearly evident. The student phase can, therefore, be regarded as a process that prepares the person to lead an ethical life in the second stage. The second stage of grihastha is associated with the maximum level of social responsibilities. This is the stage during which the most important contribution is made to the organisation and sustenance of the entire society. Therefore, a person in this stage is most in need of guidance. According to the purusharthas, this stage is of the maximum relevance in terms of promoting righteous conduct in the fulfilment of all responsibilities (dharma), as well as promoting righteous means of earning material wealth (artha) and a life characterised by integrity (10, 21). Persons who are in positions of power of any kind and whose decisions can have an impact on many people have a responsibility to make fair and just decisions, free of any personal biases. This, once again, draws attention to the relevance of dharma in research, medical care, medical administration, policy development and governance. The role of the moral foundation envisioned in the concept of dharma, during studentship as well as in building a moral citizen in later life, cannot be overemphasised. The occurrence of the theme of ‘righteousness’ is striking in the other eastern philosophy, Buddhism, as well, in the articulation of the goals of life or the eight-fold path to salvation5 (22).

An exploration of the meaning of each of these goals seems to indicate that dharma is the first, most important, and overarching goal, which extends to artha and kama. These three goals are the means to the ultimate goal of moksha. It is also evident that the aspirations of human beings are fully acknowledged and permitted – in fact, human beings are exhorted to fulfil their aspirations – but within a framework of duty on one side and spiritual attainment on the other. This is reflected also in the manner in which the goals are listed, ie artha and kama are positioned between dharma and moksha.

Attaining the goals of life

The gap between knowledge and practice in human behaviour is well known. A theoretical knowledge of dharma alone does not suffice. Some attitudes and qualities are said to be needed to practise dharma. Guidance on how to acquire those qualities is available in the scriptures and writings of all the schoolsof Hindu philosophy. Such guidance is mostly in the form of prescribing the virtues to be cultivated and advising against certain vices.

Shankaracharya’s Viveka Chudamani promotes the virtues of viveka, vairagya, shat-sampatti and mumukshutva(23). Viveka is the wisdom to discriminate; to discern between what has enduring value and what does not, in all affairs of daily life, ranging from mundane matters such as eating and drinking to more serious ones. Vairagya is dispassion or freedom from self-indulgence. Self-indulgence is considered to have no enduring value and is, therefore, discouraged. Shat-sampatti literally means a “treasure of six virtues”. It refers to cultivation of a frame of mind which is calm and quiet, and which can control negative thoughts, endure hardship with equanimity and draw mental strength from within oneself rather than depending on external support. It also includes having firm faith in the guidance offered by one’s spiritual teacher. Mumukshutva refers to an intense longing and aspiration for moksha. This intense longing appears to be the ultimate driving force of morality.

In his Yoga Sutras (aphorisms), Patanjali, prescribes adherence to the Ashtanga Yoga(24), which comprises the qualities of yama, niyama, asana, pranayama, pratyahara, dharana, dhyana and samadhi. Yama (vow of self-restraint) and niyama (disciplined daily routine) are regarded as the primary steps and the moral backbone of Ashtanga Yoga, as they cultivate an ethical discipline.

The purpose of developing all these qualities is to still the mind and distance it from the chaos of the myriad thoughts and desires that distract one. In this way, one’s thoughts will be pure, and one will experience contentment and be able to practise austerity. This will enable one to focus on higher goals.

Some of the vices that hinder human beings from performing their dharma (duty) are said to be unbridled sensual desire, avarice, envy and vicious anger. It is held that these vices can be overcome through knowledge gained from the scriptures (Jnana Yoga), unconditional devotion to God (Bhakti Yoga), or detached and selfless work (Karma Yoga). Learning about Karma Yoga(25) is useful in understanding the motivation for abiding by dharma.

In a literal sense, karma means actions and yoga means spiritual union. Therefore, Karma Yoga is described as a way of thinking, willing and acting, by which one orients oneself towards one’s spiritual goal. Humans beings are supposed to act in accordance with their dharma (duties), giving no consideration to their self-centred desires, likes or dislikes. They are supposed to act without an eye to the fruits of their deeds. They should not think about whether they will succeed or fail, as long as the performance of their deeds is marked by complete involvement and commitment to their dharma. In short, Karma Yoga is selfless action or selfless work. When one performs one’s duties or work with such an attitude, it amounts to service. The Bhagavad Gita (26) offers detailed explanations of and guidance on Karma Yoga.

It is interesting to note that the guidelines on dharma closely resemble the precepts of Deontology (27), in the sense that the morality of actions is judged by how far individuals adhere to their duty or responsibility or abide by the rules. The exhortation to cultivate virtues closely resembles Aristotle’s promotion of virtue ethics (28, 29) and Confucianism (30).

As is evident, whatever the school of Hindu philosophy, the virtues to be inculcated are very similar. Followers can pick and choose the individual philosophy according to their inclinations. The virtues embodied in Hindu philosophy have a universality, in the sense that no other religion or secular order would contradict them and, indeed, many of them find mention in the scriptures and literature of other religions, too. Practising these virtues seems a difficult task and a serious enterprise, but it appears that it would give rise to a mental attitude that promotes responsible behaviour. It promotes selflessness, an expansive worldview, moral behaviour and altruistic motives which are tangibly different from the qualities inspired by man-made regulations and constitutional law.

Dharma and current medical ethics

Most medical professionals embark on their career with a commitment to morality and ethics. However, when they enter the world of competition, and a society that values name, fame, money and power more than spiritual progress, their commitment to ethical behaviour can easily weaken. The commitment to an ethical attitude needs constant reinforcement. Dharma, both through the ethical discipline it demands in everyday life and through its theistic moorings, may provide this reinforcement. Moreover, when dharma is understood and frequently reiterated as the primary purpose of life, it may serve to balance and temper a person’s worldly aspirations.

It may be asked how dharma can actually help in the care of individual patients. Most of the existing ethical theories, be they Deontology, Utilitarianism, Consequentialism or Principlism, offer only a broad framework for action. Making an ethical decision in a particular situation still requires an interpretation of the theory. Sometimes, theories, principles or guidelines seem to be in conflict with one another, ultimately necessitating an interpretation based on the context. The theories mentioned above offer no further guidance. The person has to depend on practical wisdom to choose the right course of action. Dharma, too, provides only a framework for action. However, the virtues that must be practised to abide by dharma also promote mental discipline and practical wisdom (phronesis, according to Aristotle; viveka, according to Hindu philosophy).On the basis of this, one can make ethical, fair and practical decisions that are aligned to one’s deeply held values.

There are innumerable principles, guidelines and regulations in use today, but awakening the ethical attitude to honour them is the challenge. It must be stressed that dharma is not yet another ethical principle that can be applied to resolve ethical dilemmas – instead, it represents a way of life that awakens, promotes and sustains an ethical attitude. An awakened ethical attitude would enable a person to interpret situations wisely and judiciously apply the ethical principles and theories already in use. Guidelines, regulations and laws would then be seen as the means, and not the end, in so far as ethical behaviour is concerned. Thus, dharma would have an overarching influence on decision-making in healthcare, encompassing and extending beyond individual medical care.

Dharma could influence decision-making in many aspects of healthcare. The concept of cosmic unity (13) stresses the interconnectedness of all components of creation. Each living body is regarded as a microcosmos that is a complete reflection of the macrocosmos around, and, therefore, every human action has a consequence on the environment. An understanding of the cosmic dimension of human life may significantly influence the way we look at our world and at our behaviour in it. It may define a framework for our aspirations, be they in terms of technological progress, longevity, regenerative medicine or freedom from disease. It may provide a direction to research and scientific progress towards genuine social beneficence. Understanding the cosmic dimension has the potential to sensitise us to approach the universe with respect and awe, and to teach us to value the environment and make judicious use of diminishing resources.

When divinity is recognised in all forms of life, one will hesitate to treat any form of life merely as a means to achieve one’s own ends. This is very similar to Kant’s second categorical imperative (1), but it has a philosophical and theistic foundation that helps one understand the essence of respect for persons and informed consent.

It is now being realised that there are fundamental differences in the foundation for medical ethics between cultures. Western philosophies encourage discovery, as well as the enhancement and maintenance of individuality, the principle of autonomy being an expression of this individuality. Autonomy is, therefore, often regarded as the most important of the four ethical principles. Flowing from this concept is the tendency to demand moral behaviour from others as a matter of right. The Hindu philosophies, on the other hand, promote abnegation of the self and submergence of individuality. Those who are followers of dharma are intensely aware of their responsibilities towards others and the impact of their choices on them. Therefore, the person is most likely to focus on making choices that are the least self-centred, the least harmful and the most beneficial to others. This seems to indicate that beneficence and non-maleficence would be regarded as more important than autonomy. When social beneficence and non-maleficence drive medical care, the potential to deliver ethical care increases tremendously.

Today, there are plenty of complaints regarding the deteriorating standards of work ethics amongst medical professionals. Karma Yoga (25) offers guidance on the work ethic of professionals. Its ideals are rigid self-discipline and self-restraint, total absorption in one’s path of action, and setting high standards for oneself to provide dedicated service. To a follower of Karma Yoga, dharma would mean selfless service, working for the benefit of society and not for rewards, and aspiring for honesty and perfection in action. These translate into attending to one’s duties promptly; delivering rational, cost-effective and good-quality medical care; focusing on care rather than monetary profits; and being genuinely committed to serving the sick rather than gaining fame, wealth, position and power. They also imply that it is important to ensure the veracity and legitimacy of the results of scientific research. Most importantly, the ideals of Karma Yoga are supposed to be pursued for the self and not others. Thus, moral behaviour and self-policing are driven internally, and the need for external monitoring and regulation is not so strong. This attitude has become rare in the present age, though it is extremely important, not only for practising ethical medicine and conducting ethical clinical trials, but also for creating role models for future generations of medical students.

Karma Yoga can influence the delivery of healthcare in other ways, too. As it requires one to perform one’s duty selflessly, without an eye to the benefits of one’s success, any work done in this spirit is a service to humanity. If the philosophical foundation of one’s work consists of the submergence of ‘I’ as the achiever or doer, the submission of all the fruits of one’s actions to God, and contentment and detachment, there is bound to be a clash with concepts such as intellectual property rights and patents. In this context, Karma Yoga translates into giving greater importance to non-economic social values in the development of drugs as well as the marketing strategies for drugs. Providing medical care and conducting research to develop new treatments are regarded as one’s duty, and this duty must be fulfilled with the expectation of no more material gain than is necessary to fulfil other social responsibilities. The high cost of medical care today can be attributed partly to the pricing policies protected by patents laws and intellectual property rights and partly to personal aspirations for the accumulation of immense wealth. Would it be possible to consider a paradigm shift in which the personal benefits of research or medical skills are not demanded as a matter of entitlement, but are accepted humbly and considered a spontaneous bestowal of appreciation or gratitude by the society, based on the social worth of the achievement? Such questions are not easily resolved.

The concept of dharma has many areas in common with the current practice of medical ethics and further enriches it. When one has explored and gained a thorough understanding of the virtues, it seems that the virtue of satyam (truth) does not refer to merely speaking the truth. It means the permeation of our thoughts, words, deeds and relationships with our fellow human beings by truth. It posits the imperative for integrity in research, maintaining an appropriate relationship with patients, disclosure of medical error, transparency in the consent process, etc. It implies opposition to plagiarism and falsification of data. Ahimsa is not a matter of refraining from killing alone, nor is it mere vegetarianism. It also implies kindness and care for all forms of life. It also signifies refraining from mindlessly destroying a colleague and from causing undue harm or pain during research, as well as being judicious in the pricing of services so that the “economic violence” of sickness can be reduced. The concept of vasudhaiva kutumbakam (“the whole world is my family”) promotes a universal attitude of caring and service, which is the cornerstone of ethics in healthcare.

Conclusion

People choose their professions on the basis of their capabilities, inclinations and circumstances. Many young medical students say they chose the medical profession because they wanted an opportunity to serve others. Society has long respected the medical profession for its commitment to service and the alleviation of suffering. It is apparent that dharma and medical science have a common aim – to make humanity happier by reducing suffering. So, they could be regarded as convergent or even complementary. Albert Einstein said, “Science without religion is lame, and religion without science is blind.” Recognising this fact and assimilating it into our practice of medicine would lead to an intelligent combination of technical skills, compassionate understanding and spiritual/religious values, ultimately benefiting the very art of healing.

Present-day guidelines and policies have reduced ethics to a mere social etiquette and glibly articulated forms for informed consent. However, morality and ethics are a way of life and not something to be thought of only when providing medical care, running a hospital, making medicines or conducting research. Medical ethics is only one of the many expressions of a moral life. Ethics is also reflected in the way we treat our fellow beings, the choices we make and the aspirations we nurture, in all walks of life and at all times. If one interprets ethical behaviour from a “dharmic” perspective, ethics seems to acquire a transcendental dimension and an ontological foundation that steps beyond the domains of patient autonomy and consent forms. The dharmic perspective imparts more categorical strength to ethics and posits that ethics is articulated not merely as a legal or regulatory imperative, but also a spiritual imperative. Thus, there are enough merits in the philosophy of dharma to warrant a closer and deeper exploration of its importance to medical ethics, both in the teaching and practice of medical ethics.

Notes

1. Pertaining to the Vedas, the oldest Hindu scriptures
2. Hinduism has six orthodox schools of thought, most of which are theistic and accept the Vedas as the supreme and revealed source of knowledge, and three heterodox schools of thought, which draw upon traditions other than the Vedas too (32) (9).
3. The four stages are Brahmacharya (referring to student stage of life), Grihastha (referring to familylife and / or being a citizen), Vanaprastha (referring to the abandonment of material possessions) and Sanyasa (renunciation) (10) (34). The first two are the most relevant to this article.
4. The first part of the Taittiriya Upanishad, Shiksha-valli (12), is a section providing instruction on how the purusharthas can be attained.
5. Eight-fold path of Buddhism: right views, right resolve, right speech, right conduct, right livelihood, right effort, right mindfulness and right meditation.
6. The Bhagavad Gita (28), Shankaracharya’s Viveka-Chudamani (Jewel-crest of Wisdom) (24) and Yoga philosophy of Patanjali (25)are only some of these scriptures.
7. Shat-Sampatti – (a) sama: an inner attitude of tranquility and contentment, (b) dama: controlling wayward thoughts and actions and using the senses in a responsible way, (c) uparati: ceasing to depend on other persons or external objects for happiness, (d) titiksha: forbearance or enduring difficulties without rebellion or lamentation, (e) shraddha: faith in or firm conviction regarding the truth about the natural order of things, and (f) samadhana: remaining focused on harmony and balancing the mind, its thoughts and emotions.
8. Only an approximation of their meaning can be expressed in English. Yama refers to a vow of moral self-restraint. It is a vow of restraint against vices likes violence, falsehood, incontinence of urges, theft and greed. In a more positive sense, it could be interpreted as restraining one’s impulses and temptations so as to encourage adherence to non-violence (ahimsa), truthfulness (satya), celibacy in thought, word and deed (brahmacharya) and non-covetousness (aparigraha), and to refrain from stealing (asteya). Niyama are rituals or routines to be practised every day so that they become integrated with one’s character and give one the moral strength to abide by the vow of self-restraint. Thus, yama and niyama are interrelated.The process of following the routines gives rise to a sense of discipline and focus, which is conducive to internal and external purity (saucha), contentment (santosha) and austerity. These allow one to remain focused on spiritual goals and study (tapas and svadhyaya). Yama and niyama are regarded as the primary steps without which the rest of Ashtanga Yoga will not prove fruitful. Asana and pranayama refer to controlling the body and breathing with the help of postures of meditation and breathing exercises, respectively. These seemingly physical exercises are important psychic practices which are built on the foundation of yama and niyama and are, in turn, essential for the next four steps of Ashtanga Yoga: pratyahara (withdrawal of the mind from all external objects and all internal images), dharana (concentration), dhyan (meditation) and samadhi (unification of the self with God).
9. The arishadvarga (six negative characteristics): kama (unbridled sensual desires), krodha (unjust and vicious anger), lobha (avarice and greed), moha (infatuation), mada (vanity resulting from egoism), and matsarya (envy and jealousy) (28)