- Sunil K. Pandya, M.D.
Consultant Neurosurgeon, Jaslok Hospital & Research Centre, Dr. G. V. Deshmukh Marg, Mumbai 400026, India
Address for correspondence: Flat 11, 5th floor, Shanti Kutir, Marine Drive, Mumbai 400020, India.
Email: sunil@pandya.ilbom.ernet.in

Abstract

India has been blessed with a glorious code on medical ethics since the days of Caraka and Susruta (circa 600 BC). This Ayurvedic code embodies the criteria for a good teacher and who should study medicine. It also offers counsel on behaviour with patients and their relatives and pointers that can be used by us when dealing with such issues as brain death and organ transplantation. Especially striking is the emphasis on transcending the needs of the body, mind and intellect in order to reach a state where the cycle of birth - death - rebirth is broken.

This ancient code is reflected in the codes set up by Buddhism and Jainism - offshoots from the Hindu faith. The Islamic code of ethics was not as well defined in India. Based on the teaching in the Koran, the Muslim doctor was expected to do all he could to save life and promote morality.

Modern Indian doctors appear to have forgotten their ancient heritage. The Medical Councils in New Delhi and the various states have failed to ensure a high moral standard in the medical profession.

Introduction

The beginnings of recorded medical practice in India date back to the advent of Aryan invaders. Originating in Central Asia, they settled in the northern Indian plains around 1500 BC. They brought with them, in Sanskrit, the beginnings of the Vedas. The three principal vedas were Rg, Sam and Yajur. A later addition - the Atharva Veda - is the principal source for information on medicine during the early vedic period.

Much useful information is also to be found in the seminal Ayurvedic classics - Caraka Samhita, Susruta Samhita and Bhela Samhita (around 600 BC). The early Vedic healers were members of the priestly community. The medicine they practised and taught was heavily influenced by the philosophy of the times. Medical works also emphasised the concept of the cycle of life-death-rebirth. The student was taught that the goal of the savant was to break this cycle and attain union with Brahman - the Universal Spirit or God. One of the most popular prayers in the Upanisads reads:

"From the unreal, lead me to the real;

From darkness lead me to light;

From death lead me to deathlessness."

Techniques that helped the individual attain this goal were recorded in meticulous detail. It was recognised that few would actually succeed but all were exhorted to make the effort. Graded benefits were expected in succeeding lives depending on the extent that the individual succeeded in his endeavour in his present life.

Towards this end, ethical principles were enunciated and steps taken to ensure that they were followed. Teacher and student were reminded that the profession existed for the welfare of the patient. Whilst fair compensation was not frowned upon, the physician was constantly reminded that the primary goal was not fortune for self and family but the care of the sick.

Some Ayurvedic ethical declarations

Qualities required in a student

Not all persons are fit to be students of medicine. Acceptance or rejection of the pupils was left to the ancient Indian preceptor. The preceptor, who has set his mind on teaching, should first examine the person who presents himself as a pupil, to see that he possesses certain physical, moral and intellectual endowments.

The following are some of the requirements of the student listed by Caraka and Susruta:

• noble by nature, devoted to truth, intelligent, of a thoughtful disposition, courageous, compassionate;
• excellent character; pure in his behaviour; devoted, clever and compassionate to all;
• endowed with broad understanding, power of judgement and memory, liberal mind;
• disposed to solitude, fond of study, devotedly attached to both the theory and practice of medicine;
• self-control;
• seeks the good of all creatures;
• free from haughtiness, pride, wrath, cupidity, sloth;
• free from those faults which are grouped under the vyasanas - hunting; gambling with dice; sleeping during the day; speaking ill of others; infatuation with women; addiction to singing, dancing and instrumental music; purposeless sauntering...

Qualities required in a teacher

Not all persons can become teachers. The following are amongst the requirements of the teacher listed by Caraka and Susruta:

• compassionate towards those who approach him;
• pure of conduct;
• clever, experienced, well-disposed towards disciples and disposed to teach them;
• without malice or a wrathful disposition;
• capable of bearing privations and pain.;
• capable of communicating his ideas to pupils seeking his instructions;
• knowledge of the medical sciences has been supplemented by knowledge of other branches of study.

Duties of the teacher

Two principal duties were emphasised:

• imparting detailed knowledge of the various branches and regions of the science of life;
• explaining its philosophical basis and the real significance of the diverse information found in the various authoritative texts.

The student was not to be made to limit his studies to Ayurveda alone but was to include as much as possible of all other branches of science and philosophy which must be known for a true understanding of the human being.

The student was made to understand that the formal training is only the minimum equipment of the physician. It is only after adequate experience through years of practice, observations, further study and discussions that a person can aspire to be worthy of the profession. If he failed to keep up this schedule of constant improvement, he was to be regarded not as a true physician but merely as an impostor.

Some of the instructions to the disciple at the consecration ceremony

• It is the duty of all good physicians to treat gratuitously with their own medicines, all Brahmins, spiritual guides, paupers, friends, ascetics, neighbours, devotees, orphans and people who come from a distance as if they are his own friends.
• If you desire to achieve success of treatment and win heaven hereafter, you should always seek, whether standing or sitting, the good of all living creatures.
• You should, with your whole heart, strive to bring about the cure of those that are ill.
• You should speak words that are soft, unstained by impurity, full of righteousness, incapable of giving pain to others, truthful, beneficial and properly weighed and measured.
• Even if possessed of sufficient knowledge, you should not boast of that knowledge.
• You should give up lust, anger, avarice, folly, vanity, pride, envy, rudeness, deception, falsehood, idleness and all other reprehensible conduct.
• You should not, even in imagination, know another man's wife.
• You should not appropriate other people's possessions.
• Whilst entering the family dwelling-place of the patient, you should do it after giving notice to the inmates and with their permission. Some male member of the family should accompany you. You should cover your person properly. You should keep your face downwards. With your wits about you, you should, with understanding and mind properly focussed, observe all things. Having entered, you should not devote your words, mind, understanding and senses on anything else than what is calculated to do good to the patient or to any other object connected with the patient than his recovery.
• You should never give out to others the practices of the patient's home.
• Even if you be certain of it, you should not speak of the diminution of the period of the patient's life when such speaking may shock the patient or anybody else.
• There is no end to medical science, hence, heedfully devote yourself to it.

Some aphorisms for the student

• Unto men possessed of intelligence, the entire world acts as a preceptor. Unto men destitute of intelligence, the world occupies the position of enemy. Hence, observing all this, an intelligent man should listen and act upon the counsels of the one who is even a foe when these happen to be instructive and praiseworthy.
• The physician of knowledge, who fails to enter the inner body of the patient with the lamp of knowledge and understanding, can never treat diseases.
• Patients trust their physicians implicitly to the extent of placing their lives unhesitatingly under his care. This is true even of patients who have no trust in their own relations, parents and sons. Hence a physician should take as much care of each and every patient as he would of his own family.
• By following these principles, the physician benefits his fellow-creatures, achieves glory and merit in this world and creates a place for himself in heaven after death

Relationships between doctors

Caraka advised physicians to hold discussions with their colleagues. Discussion increases the zeal for knowledge, clarifies understanding, increases the power of speech, removes doubts and strengthens convictions. In the course of these discussions, many new things can be learnt

A friendly discussion, held between wise and learned persons who frankly and sincerely discuss questions and give their views without any fear of being defeated or of the fallacies of their arguments being exposed for in such discussions, is rewarding to all participants. Even though fallacies may be voiced, no one tries to take advantage of the other, no one is jubilant over the other's defeat and no attempt is made to misinterpret or misinterpret the other's views.

The ethics of the profession

A passage in the Caraka Samhita summed up the ethical injunctions of that time: "He who practices medicine out of compassion for all creatures rather than for gain or for gratification of the senses surpasses all. ", "Those who for the sake of making a living make a trade of medicine, bargain for a dust-heap, letting go a heap of gold. ", "No benefactor, moral or material, compares to the physician who by severing the noose of death in the form of fierce diseases, brings back to life those being dragged towards death's abode, because there is no other gift greater than the gift of life.", "He who practices medicine while holding compassion for all creatures as the highest religion is a man who has fulfilled his mission. He obtains supreme happiness."

Buddhist, Jain ethics

These follow the general principles of ethics laid down in Hinduism. The emphasis on doing all that it possible to end the cycle of rebirths prevails. Commentators have attempted to trace the relationship between such works as the Bhagawat Gita and the Dhammapada. (e.g. David J. Kalupahana: Ethics in Early Buddhism, University of Hawaii Press, 1995)

In his discourse at Benares, the Buddha enunciated the four noble truths:

"Existence is unhappiness.

Unhappiness is caused by selfish craving.

Selfish craving can be destroyed.

It can be destroyed by the following eight-fold path:

1. Right understanding
2. Right purpose
3. Right speech
4. Right conduct
5. Right vocation
6. Right effort
7. Right alertness
8. Right concentration."

In order to evolve to this state, the individual must lead a moral life, seek the welfare of his fellow-beings and renounce material wealth. In Buddhism, as in Hinduism, ethics is not merely for its own sake but is an essential ingredient on the path to the final goal. The four noble truths place before us an ideal that is especially to be cherished by the physician.

In the Dhammapada, the Buddha pointed out that all that we are is the result of what we have thought. We are, in a sense, made up of our thoughts. If a man speaks or acts with an evil thought, pain follows as the wheel follows the foot of the ox that draws the carriage. Hatred does not cease by hatred at any time. Hatred ceases by love - this is an eternal law.

The Buddha prescribed five ways by which an individual ministers to others: "By generosity, courtesy and benevolence, by treating them as he treats himself and by being as good as his word."

This philosophy also guided the Buddhist physicians of the time. In the Bodhicharyavatara of Santideva (600 AD), are passages which physicians everywhere could adopt as their credo: "In reward for all this righteousness that I have won by my works, I would fain become a soother of all the sorrows of all creatures. May I be a balm to the sick, their healer and servitor, until sickness comes never again..."; "My own being and my pleasures, all my righteousness in the past, present and future I surrender indifferently that all creatures may win through to their end…"

And later, in the same work: "Though I cannot in myself feel the pain of another as though it were my own, it is a pain to him which he cannot bear… I must destroy the pain of another as though it were my own, because it is a pain; I must show kindness to others for they are creatures as I am myself…"

In neither of these faiths has medical ethics been codified. This is not to say that Buddhists or the Jains have ignored illness and health care. On the contrary, in Buddhism, the metaphor of the Buddha as the supreme physician, who cures the ills of the world and of the individual sufferer, is an important part of the Dhamma (derived from the Sanskrit term dharma). Furthermore, caring for the sick both within and without the monastic order has always been acknowledged as being an excellent way to manifest such primary virtues as karuna (compassion) and friendship.

As in Hinduism, ahimsa (the injunction - "Thou shalt do no harm to any living being.") applies to all sentient life and is an especially dominant theme in Jainism. It forms a powerful basic concept in bioethics in these three faiths. The truth is highly valued in these faiths. In his farewell address, delivered at the age of eighty, the Buddha passed on his final words of advice: "Be ye lamps unto yourselves. Rely on yourselves and do not rely on external help. Hold fast to the truth as a lamp. Seek salvation in the truth alone."

And yet, as in Ayurveda, truth is not to be viewed in isolation. When the truth is likely to harm, compassion must over-rule this virtue. Likewise, when a lie may do good, it is condoned. In the Parable of the physician in chapter sixteen of the Lotus Sutra, the Buddha compares himself to a skilful physician. All his sons have foolishly taken some powerful, poisonous medicine. The most deranged of them refuses to take the antidote, which the Buddha has prepared. The Buddha deceives them by feigning his own death, thereby shocking them back into their right minds so that they will take the remedy. At the end of the tale, the Buddha asks: "Are there any who could say that this good physician has committed the sin of falsehood?"

Muslim ethics

Muslim ethics has always been guided by the teachings in the Koran. Muslim dominance in India dates to the establishment of the Delhi Sultanate in 1300 AD and, later, with the coming of the Mughals in 1526. This influence was principally confined to north and central India with little effect on the southern Indian peoples. The medical practice of the Muslim physicians (hakims) was drawn from that in vogue in Persia which, in turn, was of Greek and Roman origin. Codification of medical ethics is a recent phenomenon and is gaining ground especially in Saudi Arabia and the Gulf states.

Western medical influence

The advent of the Portuguese, French and, most significantly, the British into India ushered in the system of medicine that continue to dominate the subcontinent. The officers of the Indian Medical Service and of the provincial services established medical schools in different parts of the country, starting with that in Calcutta in 1835. These served not only to introduce the Indian students to principles and practice of medicine but also to the western concepts of medical ethics. To this day, discussions on ethics in India start with the enumeration of the principles of beneficence, non-malevolence, autonomy and justice.

Medical ethics in India today

India is not an underdeveloped country but a highly developed one in an advanced state of decay. - Shashi Tharoor (The great Indian novel, Arcade Publishing, NY 1989. Page 1.)

Indian doctors, schooled in Western science, are ignorant of the medical ethics of their own culture. They make a conscious effort to distance themselves from Ayurvedic medicine, in which the ethical codes are enshrined. Teachers and students forget that values have universal applicability, regardless of the mode of practice - Western or traditional - and that the patient remains the same regardless of the system.

As we examine the tangled state of Indian medical ethics, we are increasingly aware that wide sections of our ethical roofing are perched perilously. Nowhere is this crisis more pressing than in respect to issues of life and death. As we survey the scene, we find a widespread sense of moral disarray. We've had a traditional set of standards that have been disregarded and are no longer fashionable. We have lost our moral landmarks. With the breakdown of the traditional consensus, there is no more debate. The scarcity of role models for the medical neophyte only aggravates the malady.

A poor start

Unethical practices in getting entry into medical colleges as students are rampant. Private medical colleges necessitate huge capital investments by each medical student. On graduation, there is a need to recover these investments and generate profit on them as soon as the doctor starts practice.

Lack of teaching

In 1998 there was but one institution in India (St. John's Medical College, Bangalore) that offered a structured course on medical ethics throughout the undergraduate curriculum. In almost all other teaching institutions, medical ethics is dealt with cursorily, if at all. Our medical students are not made to face ethical dilemmas during their medical training. There are no sessions where real life dilemmas are highlighted and the principles to be invoked in solving them discussed.

Under these circumstances it is not surprising that students emerging from almost all our medical colleges are ill-equipped to ask questions of themselves or ponder the nature and consequences of their own actions towards patients and their families.

Inroads made by commercialism

The spirit of privatization now pervades India. Whilst the benefits have been widely publicized, the drawbacks have been little discussed. Hitherto, poor patients had free access to the best that the medical sciences had to offer at the public hospitals run by governments (central and state) and municipal corporations. These hospitals were created for the poor patient and the costs were wholly subsidized.

Rising costs and the wave of privatization have combined to throw these hospitals to the winds. Administrators and bureaucrats now seek ways to raise income from the abjectly poor patients who throng their institutions. When such funds cannot be raised, the hospitals are allowed to decay and disintegrate. In my own city, Mumbai, we are now witnesses to a public hospital being auctioned to the highest bidder.

Commercialism has had other ill consequences. Let me give you some examples. Smelling fast bucks, several individuals (some of them medical consultants themselves) or groups, have set up Computerized Tomography and Magnetic Resonance scanners in most major cities. The intense competition between these centres has engendered the pernicious system of fee splitting. The doctor referring a patient for a scan is paid a handsome fee for `pre-scan clinical workup'! Unscrupulous clinicians - and there are plenty of them - have been quick to seize this opportunity and refer every patient with a headache or a backache for such scans, often without a detailed clinical examination. It is particularly regrettable that some members of the Neurological Society are party to such practices since one of the first goals of this Society at its foundation was `to maintain the highest ethical standards in the practice of this specialty'.

The advent of corporate hospitals set up purely with a motive to make huge profits and offer dividends to their shareholders has aggravated the sharp departure from ethical practice. Chains of hospitals are being set up with a holding company, a subsidiary for making centralized purchases for the entire chain, and individual companies for each hospital. The holding company often ensures that equipment is purchased from predetermined firms, often for considerations other than merit. Channelling all purchases through a centralized subsidiary ensures fat returns on each item purchased for the entire chain. In the process, the patient pays hugely inflated costs.

Journal on medical ethics

We have but one journal on medical ethics in India -Issues in Medical Ethics. Even this is floundering for want of support. The secretary of the Department of Biotechnology, Government of India promised financial support to the journal in an open, international meeting. This promise has not been honoured. There is a newsletter of the All Indian Association of Bioethics also. Medical ethics has zero priority in the minds of administrators, teachers and students.

A general lack of character

When the subject of medical ethics is brought up for discussion at meetings of medical doctors, inevitably, someone raises an apparently logical question: "When society at large is corrupt and unethical, how can you expect doctors to remain honest?"

The question assumes that if everyone is doing wrong, we are entitled to follow suit. It also shows that most of us, in the Indian medical profession, though literate are not educated enough to be able to transcend our baser impulses. In doing so, of course, we ` bargain for a dust-heap, letting go a heap of gold'.

We have also forgotten two lessons taught in recent times. The mystic sage from Bengal, Ramakrishna Paramhansa (1836 - 1886), commented on the Indian penchant for idol worship and offered a suggestion that could be used by all Indian doctors to the advantage of their patients: "If God can be worshipped in images of clay, should He not be worshipped in one's fellow beings?"

Mahatma Gandhi (1869 - 1948) offered a talisman to be used when we are in doubt as to the course of an action or when we are obsessed with ourselves and our own wellbeing: "Recall the face of the poorest and weakest man whom you may have seen and ask yourself if the step you contemplate is going to be of use to him… Then you will find your doubt and yourself melting away…"

Suggested reading

(Note: I have only provided references to texts easily available to the Western reader.)

Basham AL (Editor): A cultural history of India. Bombay: Oxford University Press 1975.

Bhagavat Sinh Jee: Aryan medical science: a short history. Delhi: Rare Reprints 1981.

Burtt EA (Editor): The teachings of the compassionate Buddha. Early discourses, the Dhammapada and later basic writings. New York: The New American Library 1955.

Chattopadhyaya Debiprasad: Science and society in ancient India. Calcutta: Research India Publication. 1977.

Chattopadhyaya Debiprasad (Ed.): Studies in the history of science of India. Vol. 1. New Delhi: Editorial Enterprises. (Year of publication not mentioned.)

Coward Harold (Ed.): Life after death in world religions. Sir Garib Das Oriental Series No. 238. Delhi: Sri Satguru Publications (a division of Indian Books Centre) 1997. (Original publisher: Maryknoll, N.Y.: Orbis Books).

Cromwell Crawford S.: Dilemmas of life and death. Hindu ethics in North American context. Delhi: Sri Satguru Publications. 1997

Filliozat J: The classical doctrine of Indian medicine. Delhi: Munshiram Manoharlal. 1964.

Jolly Julius: Indian medicine. Delhi: Munshiram Manoharlal.1977

Kane PV: History of Dharmasastra. Pune: Bhandarkar Oriental Institute. 1973.

Kutumbiah P: Ancient Indian medicine. Bombay: Orient Longmans. 1962.

Mehta P. M. (Ed.): Caraka Samhita. Jamnagar: Gulab Kunverba Society. 1949

Mukopadhyaya Girindranath: History of Indian medicine. Vol. 1-3. New Delhi: Oriental Books Reprint Corporation 1974.

Ray P, Gupta H. N., Roy M: Susruta Samhita. A scientific synopsis. Indian National Science Academy, New Delhi. 1980.

Svoboda Robert E: Ayurveda. Life, health and longevity. Arkana: Penguin Books 1992.

Zimmer H. R.: Hindu medicine. Baltimore: Johns Hopkins Press. 1948.

Zysk, Kenneth G: Asceticism and healing in ancient India. Medicine in the Buddhist monastery. Delhi: Oxford University Press. 1991.

Zysk Kenneth G: Medicine in the veda - religious healing in the veda - with translations and annotations of medical hymns from the Rgveda and the Atharvaveda and rendering from the corresponding ritual texts. Delhi: Motilal Banarsidass Publishers Private Limited 1996.