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HANDBOOK ON MEDICAL ETHICS

Medical ethics – as prescribed by Caraka, Susruta and other ancient Indian physicians


Origin of medical science

Ayurveda originated for the preservation of human lives so that they may be dedicated without hindrance to austeritv. meditation and discinlinc of mind. It is the feeling of love and compassion for suffering humanity that first gave rise to the sages’ efforts to discover the science of medicine. (Caraka sutra VI, 7)

Aim of medical education

Outlining the objective subserved by medical education, Caraka stated, ‘This science is to be studied with a view to benefiting all creatures… with the object of attaining virtue, wealth and pleasure…’

‘Now whatever endeavour a practitioner of this science makes towards the relief of the ailments affecting those who walk in the path of righteousness or those who propagate righteousness, or of such persons as his mother, father, brothers, relations and seniors or in whatever measure he meditates on, expounds or prac-tices the spiritual truths enshrined in this science of life; all that constitutes the higher virtue of his life.’

Another early master, Kasyapa declared, ‘Medicine should be studied.. . for the sake of the knowledge of truth, of acquiring spiritual merit for himself and of exteilding help to humanity…’

Dhanwantari, the legendary god of medicine defined the purpose of the medical sciences as ‘release from suffering to those who are in the grip of disease and maintenance of well-being as regards those who arc right-healthy. Medical science is eternal, sacred and bestowed of heaven, fame, longevity and subsistence.’

Caraka and Susruta

Susruta, contemporary with Caraka, did at Varanasi for surgery what Caraka did for medicine. He compiled the Samhita named after him. Both these works, as available to us, represent not only the teachings of these masters but also additions and commentaries by followers.

Caraka Samhita and Susruta Samhita were written. around 2700 BC.

Qualifications required in a student of medicine:

Admission to studies:

As much importance was attached to moral fitness as to physical and intellectual fitness. Caraka: Knowledge like a sword or water requires a clean repository. ‘weapons, learning and water are wholly dependent for their merits and demerits on their holder.’

The oath of initiation

‘The teacher should instruct the disciple in the presence of the sacred fire, Brahmanas and physicians:

‘Thou shalt speak only the truth,. be free from envy… There shall be nothing that thou oughtest not to do at my behest except hating the king or causing another’s death or committing an act of unrighteousness or acts leading to calamity,

‘Thou shalt behave and act without arrogance and with undistracted mind, humility and constant reflection . . . thou shalt pray for the welfare of all creatures…,’

‘Day and night however thou mayest he engaged, thou shalt endeavour for the relief of patients with all thy heart and soul. Thou shalt not desert or injure thy patient even for the sake of thy life… ‘

‘Thou shalt not commit adultery even in thought. Ever so, thou shalt not covet others’ possessions… Thou shouldst speak words that are gentle, pure and righteous, pleasing, worthy, true, wholesome and moderate. Thy behaviour must be in consideration of rime and place arid heedful of past experience. Thou shalt act always with a view to the acquisition of knowledge and the fulness of equipment… ‘

‘When entering the patient’s house thou shalt be accompanied by a man known to the patient and who has his permission to enter. Thou shalt be well clad and bent of head, self-possessed and conduct thyself after repeated consideration… Having entered, thy speech, mind, intellect and senses shall be entirely devoted to no other thought than that of being helpful to the patient and of things concerning him only.’

‘The peculiar customs of the patient’s household shall not be made public. Even knowing that the patient’s span of life has come to its close, it shall not be mentioned by thee there, where if so done, it would cause shock to the patient or to others.’

‘Though possessed of knowledge, one should not boast…’

Susruta Samhita

‘Thou shalt renounce all evil desires, anger, greed,passion, pride, egotism, envy, harshness, meanness,untruth, indolence and other qualities that bring infamy upon oneself.’

‘Thou shalt clip thy nails and hair close, observe cleanliness . . . and dedicate thyself to the observance of truth, celibacy and the salutation of elders… ‘

‘The preceptor, the poor, the friendly, the travellers, the lowly, the good and the destitute – those thou shalt treat when they come to thee like thy own kith and kin and relieve their ailments…’

Kasyapa Samhita

‘O gentle one, you should be agreeable in disposition and righteous. You should control your senses and be ready to study… Share the suffering of others… and be resolute. You should be away from greed, anger,infatuation, envy, derision, enmity…’

Hastyayurveda

‘O son! You should never turn deceitful, wicked,greedy, envious, hard hearted and unfair. You should always be free from lethargy and sin and should have the character of venerable persons and compassion for the family.’

Qualities required in the student for admission to medical studies (From Caraka, Susruta, Vagbhata, Kasyapa)

  • tranquil disposition
  • nobility
  • reason and memory
  • whole of body
  • collected of mind
  • passion for study
  • undistracted of mind
  • clean habits
  • patience
  • free from greed
  • free from arrogance
  • possessed of determination
  • gentlemanliness
  • intelligent
  • large mindedness
  • unimpaired in senses
  • endurance
  • free from egotism
  • affectionate
  • free from envy
  • truthful
  • free from procrastination
  • free from bluster
  • stability and purity of mind
  • indifference to pain and pleasure
  • not given to showy appearance
  • not given to addictions
  • a predilection for philosophy
  • inclination for medical science
  • character, purity, conduct, affection, skill and compliance
  • wishing the welfare of all creatures
  • spirit, humility, strength, vitality and knowledge
  • tranquil of mind, speech and behaviour

Qualities of the teacher:

  • high exceptional abilities both moral and intellectual
  • an undenying source of knowledge and inspiration to his pupils
  • required to know the whole science, allied sciences and arts thoroughly and exhaustively
  • able to supplement texts by his own comments drawn systematically from his own experience and logic
  • possess the necessary powers of expression and exposition and clarity
  • an undistracted mind
  • make teaching his sole task in life. and devote all his energies to it
  • unbounded affection for his disciples
  • devote personal and individual care over every pupil and be his source of inspiration and guidance through life
  • the teacher cannot withhold from his pupils any aspect or recondite doctrine regarding the science he undertook to teach.

Ethics in practice

‘Having finished his studies… he should go about… with undeluded mind and with his eyes looking straight before him. He must be genial and take the initiative in a conversation. He must never resort to the patient’s house uninvited.’

‘Having entered.. . he should not turn his gaze to anything but the patient…He should not broadcast the secrets or the shortcomings of the patient’s household. ‘He should not withhold from the patient the untoward prognostic signs that he may have perceived. He should continually offer consolation to the patient.’

‘He should not administer the medicine in the wrong order nor should he delegate the responsibility to another… He must be versed in the knowledge of characteristics of constitution, drugs, disease and age… He should be given to speech that is bold, unambiguous, prompt, vivid, charming, gentle, persuasive, comprehensive, non-contradictory and righteous… If he is attacked in debate by another physician he must be able to take his stand against him. The opponent should be persuaded by gentle words…’

Fees, presents and remuneration to medical men

‘This science of life is permanent and yielding merit… Those who, for the sake of a living, make merchandise of medicine bargain for a dust-heap, letting go a heap of gold… Practice of medicine is never fruitless, it sometimes gives money, sometimes religious merit, sometimes renown or sometimes the opportunity for study…’

Dealings with women

‘His attitude to women should be particularly aloof and detached. When he enters a patient’s house he should keep his head bent and not be curious about things and persons about him. If he has to enter to treat a woman, he should never go unaccompanied and he should never laugh nor smile nor exchange irrelevant words with her. No gifts offered by her in the absence of her husband should be accepted. Even if he discovers her attachment to him and her amorous overtures, he should not respond. Neither should he divulge them to others.’

The Kasyapa Samhita is emphatic on the subject. ‘In the household of the patient he should never engage himself in joke with women, even with female servants. He should not utter their names without prefixing terms of reverence.. . He should not try to have any transaction with or great attachment to them. He should accept nothing from the woman without the knowledge of her husband. He should never enter without informing beforehand. He should neither talk nor sit with a woman in privacy. He should never look at her when she is uncovered nor laugh at her…’

Medicine a lifelong study

‘There is no limit at all to the Science of Life. So thou shouldst apply thyself to it with diligence. This is how thou shouldst act. Again thou shouldst learn the skill of practice from another without carping. The entire world is the teacher to the intelligent and foe to the unintelligent. Knowing this well, thou should listen and act according to the words of instruction of even an unfriendly person, when they are worthy… ‘

‘The intelligent person who is aspiring to be a good physician should always persevere to do his best in the acquisition of the true qualities of a physician so that he may be a real giver of life to people…’

The ideal physician

‘He is well-born, of wide learning, of wide practical experience, skilful, pure, practised of hand, self-controlled, fully equipped with all the appurtenances (of healing), in full possession of his faculties, conversant with the normal course of nature, able to take prompt and appropriate decisions… he is to be known as the saviour of life and destroyer of disease…’

Types of medical practitioners

‘Three kinds of medical practitioners are found in the world; firstly, the imposters in physician’s robes; secondly, the vain-glorious pretenders and thirdly, those endowed with the true virtue of the healer.’

‘Those who by parading their medical paraphernalia, books, smattering of medical texts and knowing looks acquire the title of physician are the first kind, viz. the ignoramuses and imposters.’

‘Those who by laying claim to association with persons of established wealth, fame, knowledge and success while they themselves have none of these things and arrogate to themselves the designation of physicians, are vain-glorious pretenders…’

Quacks

The period succeeding the Vedic retained its respect for the healer though by then imposters known as Kuvaidyas or Kuhakas (from which the modern term quack is derived) had made their appearance in society and were increasing in number.

‘Those who, putting on the garb of the physician, thus gull their patients just 1s the bird-catchers in the forest gull the birds by camouflaging themselves in nets. Such persons, outcasts from the science of healing, both theoretical and practical, of time and measure, are to be shunned for they are the messengers of death on earth. The discriminating patient should avoid these unlettered laureates who put on the airs of physicians for the sake of a living. They are like serpents that have gorged on air…’

‘One may survive the fall of a thunderbolt on one’s head but one cannot expect to escape the fatal effects of medicine prescribed by an ignorant physician…’

‘Like a blind man groping about with his. hands in fearful uncertainty or like a rudderless canoe left to the mercy of the winds, the ignorant physician proceeds in his work, full of uncertainty and fear…’

‘Emboldened by meeting with providential success in his treatment of a patient destined to survive (both the disease and his ministrations) the pretentious quack hastens to death a hundred others whose tenure o life is not so definite…’

‘The pretentious and obstreperous wiseacres are generally given to much and loose talk. The godly are generally fair-spoken and are circumspect and of few words…’

‘Tricking themselves out in the height of medical fashion they walk the streets with a view to picking up practice. Immediately on hearing that somebody is ill, they swoop down on him from all quarters and in his hearing speak loudly of their medical attainments. If a doctor is already in attendance, they make repeated mention of his failings. They try to ingratiate themselves with the friends of the patient by suave manners, knowing whispers and officiousness… On being entrusted with a case they look out on all sides repeatedly, trying to cloak their ignorance.’

‘Finding themselves unable to check the course of the disease, they give it out that it is the patient himself who is wanting in the necessary appurtenances, in attendants and in self-control. When they real& that the patient is at death’s door they make themselves scarce and seek another ncighbourhood.’

‘In the presence of uncultured people they brag about their adroitness in the most unadroit manner and like the ignoramuses they are, they run down the learned savants. But if they sight a company of the learned, they slink away from a distance…’

Euthanasia

Caraka championed the principle of good death and quoted an ancient example in support.

“The heroic Bhishma turned to Duryodhana the king and said, ‘Give generous and befitting presents of money to these good surgeons and pay them due honor and send them away for to me in this condition no treatment is welcome… I must be allowed to die…” ‘

Jain philosophy (Bhagavati-Aradhana) has long permitted an aspirant to embrace ritual death under the following conditions:

  1. when one suffers from an incurable disease,
  2. when one encounters severe famine,
  3. when one encounters conditions that make the maintenance of one’s spiritual life impossible.

Great philosophers – often termed saints – have also embraced ritual death upon realising the illusive character of the world. Most such deaths were achieved by fasting, solid foods being abandoned at first and then liquids as well. The corpse of such an individual was to be allowed natural decay and destruction rzther than funerary and crematorial disposal.

Dealing with the king

‘Attendance on a king is as dangerous as a sport with weapons, snakes and fire. It can only be discharged by modest persons though with great dexterity… ‘

‘At all times, the physician’s speech should be consistent with the ends of righteousness and the king’s welfare. He should not proffer counsel unless solicited for such gratuitous advice might easily be deemed a great presumption… If he wishes to advise the king against an evil course he should do so in strict privacy and in words that are noble and dignified. But even this he should do only when indifference on his part would be blameworthy. If such advice is met with a rebuff, the physician should hold his peace.’

‘While at court, he should avoid confidential conversation with any other than the king himself. He should also eschew gossip-mongering, hostile disputation, imitating the king either in his sartorial habits or in his pleasures and recreations…’

‘When a secret relating to someone else is being narrated the physician should seem as though he were dumb. When a secret concerning himself if being divulged he should put on the quadruple armour of deafness, fortitude, sweetness and perfect ease of manner.’

‘He should not take… pains with the object of putting himself in a(n)… exalted position for it will be found that the joy of soaring high cannot compensate for the pain of the fall when it comes…’

‘Though closely associated with the royal person, the physician is not to strain that intimacy in any way nor press it to selfish advantage… He should not speak lies nor back-bite against others….’

Suggested Reading:

  1. Mehta PM (Editor): The Caraka Samhita. Expounded by the worshipful Atreya Punarvasu. Compiled by the great sage Agnivesa and redacted by Caraka and Drdhbala. Six volumes. Shree Gulabkunverba Ayurvedic Society, Jamnagar. 1949.
  2. Settar S: Pursuing death. Institute Karnataka University, Dharwad. 1990.
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