Ethics in the medical practice of Allopathy has been a subject of innumerable debates, seminars and conferences. But the ethical issues at the interface and overlap of Allopathy and Ayurveda have received scant attention so far. India is the world leader in pluralism of medicine, with more than half-a-dozen officially recognised systems of medicine. Hence, the ethical, legal, socioeconomic and technical problems raised in such a milieu of ‘mixopathy’ are significant challenges to patients, physicians and the community.

In view of a long personal knowledge and experience of such problems, I would like to present some case studies which illustrate some of these ethical dilemmas and then discuss the general considerations necessary.

Ethical adequacy in medical practice is evaluated on four basic principles: respect for a person’s autonomy and choices; beneficence or an obligation to help or benefit; lack of maleficence or an obligation not to harm; and justice or fairness, which involves proper adjudication between competing claims for equity for medical care, often despite scarce resources. However, these values vary significantly in different cultures and even different settings of the same culture. These variances have to be studied according to the situation and the ethical values of the parties involved, against a global backdrop of the basic principles.

When a standard treatment exists

A 13-year-old girl was diagnosed to have hypothyroidism by standard thyroid hormone assays. She was advised thyroid replacement therapy by an endocrinologist, who stressed that medicine had to be taken for her lifetime. A practitioner of an alternative system of medicine, with “a reputation to have cured what Allopaths cannot achieve”, promised a cure and asked the girl’s parents to first withdraw the thyroid hormone. The girl was treated with several herbal remedies and a rigid diet. She steadily deteriorated and eventually died of the complications of hypothyroidism.

Here, the autonomy of the parents and the girl should have been curbed by the community. The ignorant practitioner of the alternative system should have been prevented from his misadventure. In short, where hormone and vitamin replacements have, for long, shown conclusive benefits, no such unproved method should be ethically permitted.

More frequent joint consultations across the systems of medicine would be ethically and technically desirable in such situations. The basics of dietetics or nutrition, infections and endocrinology should be taught to students of all systems of medicine. It is unjust to deny the benefits of wellproved replacement and antimicrobial therapy to patients due to inadequate training.

Old, tried and tested

A nephew of a trustee of a ‘five-star hospital’ in Mumbai was diagnosed with viral hepatitis. He was put under the care of an eminent gastroenterologist of that hospital, who had an overt disdain for Ayurveda or other alternative systems of medicine. Despite the Allopathic care, over the weeks the patient turned deep yellow and tests showed a steady increase in the serum bilirubin. As the patient grew anxious, the family called me in for a consultation for a possible Ayurvedic treatment of jaundice, and the gastroenterologist concerned did not object. By that time, our doubleblind controlled trials of Ayurvedic drugs in viral hepatitis were published and widely read with interest. I prescribed some simple medication that has been used in Ayurveda for centuries. Within three days, the patient showed a dramatic response and in a week’s time, his serum bilirubin was normal. The gastroenterologist and his genre still pooh-pooh hepatoprotective agents, though many cases have responded similarly.

Such Allopaths continue to deny the value of simple remedies like Kutki (Picrorrhiza kurroa) to such patients. Now, the CDRI has actively taken up study of the plant and there are international patents on the principle of the plant as a hepatoprotective agent. However, when the Nobel laureate Baruch Blumberg and his colleagues showed the beneficial effects of Bhumiamalaki-Phyllanthus amarus in hepatitis B, this was enthusiastically taken up in India notwithstanding three failures to confirm the results. Have we to always wait for western science to validate remedies, which have been used in India for thousands of years? Practitioners of Allopathy should be more open and invite joint consultation and management for the beneficence and justice of patients.

While Rauwolfia serpentina was used for many years in India for hypertension, globally many lives were lost and complications developed because this Indian contribution was ignored by the world until reserpine was isolated and marketed as Serpasil for millions of dollars globally. This was not fair. Digitalis plant extracts were used and benefited much before digoxin was isolated and commercialised. Even now, many patients of chronic diseases, who receive combined care of different systems in a judicious manner, show good response with less side effects. For example, Chandraprabha is a good complementary medicine for diabetic patients. Should we deny its use?

At Bharatiya Vidya Bhavan’s SPARC, Ayurvedic physicians, clinical specialists and integral practitioners regularly use methods of diagnosis from both Ayurveda and Allopathy. The patients accept and even look forward to such joint care, for better results. Beneficence is served and patients’ autonomy is respected by this model of integral medical care by two systems. It is ethical to offer the best of both systems, in a complementary manner.

When systems interact

However, there are ethical dilemmas based on technical problems in certain diseases, where drug interactions could be harmful. For example, Kshirsagar, at KEM Hospital, Mumbai, observed that the blood levels of the antiepileptic drug Dilantin were reduced with the concurrent administration of an Ayurvedic formulation. This may lead to lack of control of epilepsy. A list of diseases should be drawn where interactions could be hazardous and combined treatment has to be of definite benefit. It would be ethically desirable that practitioners of both systems consult clinical pharmacologists for likely interactions.

There are physicians who have dual knowledge and skills in both Ayurveda and Allopathy. When patients exercise their choice to go to them, are the patients selecting integral medicine? There are scarce data on the subject. But there are survey findings which show that despite such dual skills, many practitioners use modern drugs and injections more often than Ayurvedic drugs. In contrast, many traditional vaidyas use Ayurvedic drugs more and modern drugs occasionally, only if necessary. There is still a small fringe of shudh Ayurveda practitioners, who never use modern drugs even if these are necessary. It is desirable to consult proper pharmaco-epidemiological surveys of physicians, patients and respective modalities of diagnosis and treatment. The survey instrument should also assess patients’ choice, benefit, side effects, etc. In a pluralistic medical scene, such a survey could provide baseline data for corrective steps needed for ethical adequacy.

Emergency and acute surgical care are currently excellent in modern medicine. For example, cardiopulmonary resuscitation (CPR) has emerged from the basic advances in physiology, anaesthesiology and pharmacology. We should assess how these techniques are being conducted at Ayurvedic hospitals. If even nonmedical people are to be trained in the basics of first aid and CPR, shouldn’t the practitioners of all systems be educated or retrained as well? That would be an ethical step by the community and the government. I have seen some practitioners of certain systems helpless in an emergency due to a lack of training as well as experience. That has to be remedied as fast as possible. Ignorance in CPR is hazardous.

‘Short-course Ayurveda’

There is now an international demand for Ayurveda. In the USA and other countries, some persons undergo a nine-month course in Ayurveda and ‘practice’ as health providers. Recently we met such ‘practitioners’ at a conference on Ayurveda in New York. Such short courses cannot equip people without a medical background with the proper skills and knowledge of Ayurveda. The government of India’s Ayurvedic Council should write to the governments concerned to stop such ‘centres of Ayurveda’. Instead, good courses of longer duration should be evolved for qualified doctors of Allopathy or osteopathy. Then patients can get reliable benefits of integral medicine by well-trained doctors.

The Supreme Court’s verdict on the cross-system use of medical modalities has led to innumerable debates and meetings. Both patients and doctors were confused about the legal consequences of an Ayurvedic physician using modern drugs and an Allopath using Ayurvedic drugs. The patient’s autonomy in choosing a doctor has hardly featured in these debates It is time that practitioners are transparent with the community that they serve, about their own training, experience and skills. Just as menus are displayed outside restaurants, information on the training, degrees and experience of a doctor should be displayed at the clinic, in a language that patients can grasp.

Quackery, east and west

Currently there is widespread ignorance on health matters, particularly due to illiteracy. As a consequence, given the inability to make an intelligent choice, people are drawn even to quack doctors by word of mouth and blind trust.

However, quackery and unethical practice are not the monopoly of practitioners of any one system of medicine. The patient who gets such shotgun prescriptions must challenge it, and complain to the authorities. Currently there are hardly any prescription audits of practicing doctors, or post-degree evaluations of their updated medical knowledge or skills. The Medical Council of India, as I understand, is quite a bureaucratic body and ineffective in ensuring ethical and medical standards. How can such a body ensure quality medical practices, in a nation where corruption has become almost a way of life?

Finally, for the ethical adequacy of Integral Medicine, we must:

• Educate the community and patients on their rights and responsibilities in the proper choice of doctors
• Enforce ethical standards and report quacks to the authorities
• Survey the urgent ethical problems in our pluralistic health scenario, at the national level, and attend to the priorities in a phased manner
• Create a professional forum for debate on the ethics and emerging issues in Integral Medicine.